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116 (. i<- J 

A SYSTEM 



OF 



OEAL SUEGEET: 



BEING 



A CONSIDERATION OF THE 



DISEASES AND SURGERY 



OF THE 

MOUTH, JAWS, AND ASSOCIATE PARTS. 



BY 



\ ■ irroa,^/ 



JAMES E. GAEKETSON, M.D., D.D.-S., 

Oral Surgeon to the Medical Department of the University of Pennsylvania; Author of Diseases 

and Surgery of the Mouth, Jaws, and Associate Parts ; late Lecturer on Anatomy and 

Surgery in the Philadelphia School of Anatomy ; late Professor of the Principles 

and Practice of General Surgery in the Philadelphia Dental College; 

Member of the Philadelphia Pathological Society; Member of 

the Odontography Society of Pennsylvania ; Member of 

the Delaware County Medical Society, etc. 



IJtetaM ivittx gttmnw gHttl glflt** xM WMA-Wnts. 



PHILADELPHIA: 

J. B. LIPPINCOTT & CO. 

18 V 3. 









Entered according to Act of Congress, in the year 1872, by 
J. B. LIPPINCOTT & CO., 

In the Office of the Librarian of Congress at Washington. 



Lippincott's Press, 
Phil ad elphia. 



TO THE 

LEARNED AND DISTINGUISHED GENTLEMEN 

CONSTITUTING THE CORPS, 
PROFESSORIAL AND CLINICAL, 

OF THE 

UNIVERSITY OF PENNSYLVANIA, 

WITH WHOM IT IS THE PLEASURE AND PRIVILEGE OF THE AUTHOR TO BE 

ASSOCIATED, 



PREFACE 

TO THE SECOND EDITION. 



The kind reception accorded to the volume of which 
the present one — though greatly modified and enlarged, 
and under a different title — may be considered a second 
edition, has aroused the warm gratitude of the author, 
and stimulated him to exertions which he trusts will be 
found to have rendered the present effort more worthy of 
the commendations so generously bestowed upon his labors. 

Since the issue of the previous work — a period of rather 
more than two years having elapsed — the author has de- 
voted himself somewhat exclusively to investigation and 
observation in the direction of the specialty herein dis- 
cussed. Favored happily with opportunities not commonly 
enjoyed both in the direction of hospital and of private 
practice, he may not but feel satisfied of the value and 
solidity of the experiences and teachings here recorded. 

The present volume has been entitled a system: a 
system the author has exerted himself to make it ; step 
by step, from the elements of the subject — from the first 
departures from normal life — attempt has been made to 
follow the various conditions to and through their pro- 
foundest complications. 

During the time of writing the book, the author has 
had continuously in mind the recognition of the important 
fact that in no department of medical science has there 
existed a hiatus such as that found to-day between general 
surgery and dentistry, — a lacking span, truly, in the bridge of 
practice. A patient with an oral disease of any complexity, 
trusting himself to the average dentist, meets with disaster 
because of the absence of surgical knowledge and skill. 
Approaching from the side of medicine, he suffers alike from 

(v) 



vi PREFACE TO THE SECOND EDITION. 

the want here of a special character of information which 
has hitherto been looked upon as having relation alone with 
a specialty. 

To bridge this gap by supplying the lacking span is the 
highest ambition, as it has been the almost life-long labor, 
of the author. Any sacrifice that may have been made 
in the work, and in the preparation of the present volume, 
will find ample compensation, if the dental practitioner 
learn from it that an acquaintance with the principles of 
medicine is necessary to the comprehension of oral surgery ; 
and, on the other hand, if the general practitioner be led to 
perceive the necessity for a familiarity with that which hith- 
erto has been deemed to belong exclusively to the province 
of the dentist : that both may realize that oral surgery is a 
specialty to which no man may bring learning and skill 
which shall not find abundant opportunity for their highest 
expression. 

How oral surgery shall be practiced, whether by the 
general surgeon, or, as in ophthalmic surgery, by a special- 
ist, the author is not concerned to discuss : what is for the 
highest good comes through a law of its own to grow 
into usage. What is to be the manner of the medical 
practice of the future may safely be left to that future. 

To his publishers, for a liberality which, as the volume 
will show, involved a large latitude in expense; to S. 8. 
White, Esq., for the unstinted use of his valuable collection 
of cuts, and for numberless favors, — the conferring of which 
must have cost much trouble ; to Dr. Butler, publisher of 
the "Medical and Surgical Reporter," for cuts, and also 
to Messrs. Johnson & Lund and to Mr. Kolbe, for similar 
favors, the author returns his sincere thanks. 

To his friends and clinical assistants, Drs. De Forrest 
Willard and Elliott Richardson, for aid in preparing the 
index, and to Dr. Vallette, for drawings made of clinical 
cases, he desires to express his obligations. 

Philadelphia, 1537 Chestnut Street, 
Nov. 1, 1872. 



PREFACE 

TO THE FIRST EDITION. 



In the fulfillment of many promises made from time 
to time to his students and other friends, the author has 
prepared the following pages, as embodying the results of 
his observations and experiences during a somewhat ex- 
tended practice in that branch of the profession to which it 
specially relates. 

With the hope that the volume will be a useful text-book 
in assisting the student to prepare for the responsible duties 
of the profession, and a reliable guide to the intelligent 
practitioner, it is herewith offered to the attention both of 
those who are about to enter the field of their labors and of 
those who, though more familiar with the practical duties 
thereof, may desire to acquaint themselves more fully with 
the latest methods of practice. 

That the work may prove a source of benefit to his fellow- 
beings is the highest hope concerning it of 

The Author. 



CONTENTS. 



CHAPTER I. 

PAGE 

Surgical Anatomy of the Mouth and Face 29 

CHAPTER II. 
The Mouth 57 

CHAPTER III. 
The Fifth Pair of Nerves 77 

CHAPTER IV. 
Dentition 93 

CHAPTER V. 
Dentition — Continued 101 

CHAPTER VI. 
Associative Lesions of First Dentition Ill 

CHAPTER VII. 

Anomalies of Second Dentition and their Surgical Relations. 141 

CHAPTER VIII. 

The Teeth and their Diseases — Alveolar Abscess 170 

CHAPTER IX. 
Anchylosis of the Jaw 182 

CHAPTER X. 
Dental Caries 214 

CHAPTER XI. 
The Local Treatment of Dental Caries 274 

(Ix) 



X CONTENTS. 






CHAPTER XII. 

PAGE 

Filling Teeth 281 

CHAPTER XIII. 
Filling Teeth— Continued 307 

CHAPTER XIV. 
Odontalgia 3G1 

CHAPTER XY. 
Filling the Pulp Chamber and Canals 384 

CHAPTER XVI. 
The Extraction of Teeth 395 

CHAPTER XVII. 

General Remarks on Extraction of Teeth, Local Anaesthesia, etc 422 

CHAPTER XVIII. 
General Anaesthesia — Ether 431 

CHAPTER XIX. 
General Anaesthesia — Chloroform 441 

CHAPTER XX. 
Artificial Dentures— Pivot and Plate Teeth 456 

CHAPTER XXI. 
Irregularities of the Teeth 478 

CHAPTER XXII. 
Salivary Calculus 495 

CHAPTER XXIII. 
Denudation of Dentine 505 

CHAPTER XXIV. 
Salivary Fistulae 507 

CHAPTER XXV. 
The Tonsil Glands 516 



• 



CONTENTS. xi 



CHAPTER XXYI. 

PAGE 

The Gums and their Diseases 532 

CHAPTER XXVII. 
Caries of the Maxillae 552 

CHAPTER XXVIII. 
Necrosis of Maxillae 566 

CHAPTER XXIX. 

Wounds of the Mouth and Associate Parts 598 

CHAPTER XXX. 
Fractures of the Maxillary Bones 623 

CHAPTER XXXI. 
Dislocation of the Inferior Maxilla 637 

CHAPTER XXXII. 
Ozaena 644 

CHAPTER XXXIII. 
The Antrum of Highmore, and its Diseases , 658 

CHAPTER XXXIV. 
The Aphthae 674 

CHAPTER XXXV. 
Ranula 695 

CHAPTER XXXVI. 
Neuralgia 709 

CHAPTER XXXVII. 

The Tongue and its Diseases 756 

• 

CHAPTER XXXVIII. 
Tumors, General Consideration of 804 

CHAPTER XXXIX. 
Tumors of the Mouth — the Epulides 819 



• 



xii CONTENTS. 

CHAPTEE XL. 

PAGE 

Tumors of the Mouth — Exostosis 833 

CHAPTEE XLI. 
Tumors of the Mouth — Cystic Tumors 846 

CHAPTEE XLIL 
Tumors of the Mouth — Non-explainable Tumors 874 

CHAPTEE XLIII. 
Tumors of the Mouth — Non-explainable Tumors 895 

CHAPTEE XLIY. 
Epithelioma 918 

CHAPTEE XLV. 
Tumors of Parts associated with the Mouth 932 

CHAPTEE XLVI. 
Operations upon the Lips and Cheek 952 

CHAPTEE XLVIL 
Operations upon the Lips and Cheek 973 

CHAPTEE XLVIII. 

Ehinoplastic and Ehmo-cheiloplastic Operations 999 

CHAPTEE XLIX. 
Palatine Defects and their Treatment 1009 

CHAPTEE L. 
Obturators 1030 

CHAPTEE LI. 
Eesections of the Maxillary Bones 1058 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Front and lateral region of the skull , 30 

2. Superior maxillary bone of the left side— outer view 33 

3. Superior maxillary bone of the left side — inner view 33 

4. Inferior maxillary bone 38 

5. Palate bone of right side — posterior view 41 

6. Palate bone of right side — exterior view 41 

7. The vomer — view of left side 43 

8. Articular relations of vomer 44 

9. Position and relations of turbinated bones 45 

10. Ethmoid bone — general view 46 

11. The sphenoid bone — upper view 48 

12. The sphenoid bone — front view 49 

13. Anterior view of the nasal bone 52 

14. The malar bone— outer view 53 

15. The lachrymal bone — external view 54 

16. The hyoid bone 55 

17. Antero-posterior section of cranium 55 

18. Right half of the base of the skull 56 

19. Muscles of the face 59 

20. Arteries of the face 60 

21. The common carotid, with its divisions 61 

22. Nerves of the face 63 

23. Veins of the face 64 

24. Sectional view of the nose, mouth, and pharynx 66 

25. Side view of the muscles of the tongue 67 

26. Upper surface of the tongue 68 

27. Papillae of the tongue — moderately magnified 70 

28. Diagram of papillae — highly magnified 70 

29. Vertical section of the articulation of the lower jaw 75 

30. External view of the temporo-maxillary articulation 75 

31. General view of the relations of the fifth pair of nerves 77 

32. Trifacial division and ganglia 78 

33. Superior maxillary nerve 82 

34. Inferior maxillary nerve 84 

35. Ophthalmic ganglion— the outer part of the right orbit removed 87 

36. View of the spheno-palatine ganglion, the outer wall of the left nasal 

cavity, and the olfactory nerve 88 

37. Deciduous teeth 93 

38. Permanent teeth of superior jaw 94 

( xiii ) 



xiv LIST OF ILLUSTBATIONS. 

FIG. PAGE 

39. Permanent teeth of inferior jaw.. 94 

40. Lateral view of the upper and lower permanent teeth 95 

41. Vertical section of a molar tooth 96 

42. Transverse section of a molar tooth 96 

43. Vertical section of a cuspid tooth 97 

44. Dental pulp — magnified 98 

45. Nerves of dental pulp... 98 

46. Tubuli of dentine and enamel 98 

47. Vertical section of the fang of a canine tooth. 98 

48. Three enamel columns — highly magnified 99 

49. Section of enamel — highly magnified 99 

50. Interglobular spaces in dentine 99 

51. Diagram of the mode of development of the teeth 107 

52. First and second dentitions • 109 

53. Einged tooth 153 

54. Metal cap used in periodontitis 155 

55. Sac of alveolar abscess 170 

56. Kolbe's wedge screw 207 

57. Wedge of Scultetus 208 

58. Modified oral wedge 208 

59. Superior dental arch — perfect type of 251 

60. Superior dental arch — faulty type = 251 

61. Structural consolidation of dentine 275 

62. Hoe excavators and modifications of 287, 288 

63. Hatchet excavators and modifications of 288 

64. Eose and spear drill 288, 289 

65. Merry's drill 290 

66. Bur thimble. 290 

67. Forms of chisels used'in dentistry 291 

68. Jack's double-end enamel chisels 292 

69. Forbes's gouge, and Jack's paraboloid chisels 293 

70. Separating file— Taft's pattern 294 

71. File-carrier 294 

72. Simple cavities on grinding face of molar teeth 294 

73. Cavities on posterior face of incisors 295 

74. Neck cavities in incisor teeth 295 

75. Cavities of imperfect enamel 295 

76. Cavities on buccal face of molar teeth 295 

77. Buccal cavities 296 

78. Carious denture 297 

79. Separating files 297 

80. Complicated dental cavities 298 

81. Complicated dental cavities , 299 

82. Complicated dental cavities 300 

83. Complicated dental cavities 300 

84. Excavators, lathe matrices, and bur drills 301 

85. Forms of files used in separating molar teeth 303 

86. Mouth mirror 306 

87. Mouth mirror 306 



LIST OF ILLUSTRATIONS. xv 

FIG. PAGE 

88. Syringe 306 

89. Syringe 306 

90. Plain-pointed plugging instruments 307 

91. Serrated-pointed plugging instruments 307 

92. Flagg's tongue-holder 309 

93. Morrison's duct-compressor 309 

94. Dibble's saliva-pump 310 

95. McQuillen's extension-finger 311 

96. Taft's thimble 311 

97. Kich's Stenonian-duct-compressor 312 

98. Hodson's rubber -dam appliances 315 

99. Forbes's fork for fixing rubber dam , 320 

100. Hot-air syringe 321 

101. Foil-carrier 323 

102. Eedman's pluggers 324 

103. White's head-rest 326 

104. Jack's matrix 330 

105. Jack's matrix 331 

106. Fixing points for Jack's matrix 331 

107. Jack's matrix 332 

108. Jack's plugger-point 334 

109. Outline contour cavities 335 

110. Atkinson's pluggers 338 

111. Atkinson's burnishers 339 

112. Butler's pluggers 339 

113. Yarney's pluggers 340 

114. Abbott's pluggers 341 

115. Plugging mallets 343 

116. Automatic plugger 347 

117. Electro-magnetic mallet 348 

118. Finishing files 351 

119. Bur and wheel files 352 

120. Set of burnishers 352 

121. Porte polishers 353 

122. Filed teeth 357 

123. Diminished pulp-chamber 377 

124. Diminished pulp-chamber 377 

125. Secondary deposit of dentine 378 

126. Pulp nodule 379 

127. Pulp nodule 379 

128. Nerve extractor, with holder 385 

129. Nerve extractors 385 

130. Nerve-canal pluggers 387 

131. Permanent teeth of upper jaw 396 

132. Permanent teeth of lower jaw 396 

133. Upper incisor forceps 397 

134. Lateral incisor forceps — upper 398 

135. Lower incisor forceps — hawk-bill 398 

136. Lower incisor and bicuspid forceps, for either side 398 



xvi LIST OF ILLUSTRATIONS. 

FIG. PAGE 

137. Hawk-bill forceps for lower incisor and crowded teeth 398 

138. Upper and lower root forceps — half curved 400 

139. Lower root forceps — full curved 400 

140. Upper and lower bicuspid forceps 400 

141. Upper back root forceps — universal 400 

142. Half curved, narrow beak forceps 400 

143. Upper bicuspid and canine forceps 401 

144. Upper bicuspid and incisor forceps 402 

145. Lower bicuspid and canine forceps 402 

146. Lower bicuspid forceps 403 

147. Upper bicuspid forceps — safety 403 

148. Upper molar forceps — right and left 403 

149. Upper molar forceps 404 

150. Upper molar forceps 404 

151. Upper molar forceps — for either side 405 

152. Cow-horn forceps — right and left 406 

153. Upper molar cow-horn forceps — either side 407 

154. Lower molar forceps — either side 407 

155. Lower cow-horn forceps 408 

156. Lower cow-horn forceps — right side 408 

157. Lower cow-horn forceps — leftside 408 

158. Wolverton's forceps 409 

159. Hutchinson's forceps 409 

160. Upper dentes sapientise forceps 410 

161. Physick's forceps 410 

162. Forceps for wisdom-teeth — lower side 411 

163. Fulcrum forceps 412 

164. Fulcrum forceps 412 

165. Fulcrum forceps , 412 

166. Fulcrum forceps 413 

167. Elevators used in extracting roots of teeth 413 

168. Eelation of fractured roots to alveolar line 414 

169. Stellwagen's incising forceps 415 

170. Stellwagen's incising forceps 416 

171. Screw for extracting roots of teeth 416 

172. Dubs's screw forceps 417 

173. Hullihen's screw forceps 417 

174. Root forceps 418 

175. Root forceps 418 

176. Root forceps 418 

177. Root forceps 418 

178. Root forceps 419 

179. Root forceps 419 

180. Root forceps 419 

181. Anomalous teeth 419 

182. Anomalous teeth 421 

183. Anomalous teeth 421 

184. Spray apparatus — hand instrument 429 

185. Spray apparatus — foot instrument 430 



LIST OF ILLUSTRATIONS. xvii 

FIG. PAGE 

186. Pivoted tooth 456 

187. Excising forceps 458 

188. Excising saw . - 459 

189. Pivot files 459 

190. Hand-lathe 460 

191. Foot-lathe 461 

192. Impression tray 468 

193. Impression tray 468 

194. Impression tray 469 

195. Irregular denture 481 

196. Irregular denture 481 

197. White's, J. D., correcting plate 483 

198. Westcott's, A., correcting plate 483 

199. Irregular denture 485 

200. Correcting bars 485 

201. Irregular denture with correcting band applied 485 

202. Irregular denture 486 

203. Correcting appliances 486 

204. Correcting appliances 486 

205. Corrected denture 487 

206. Metal cap for front teeth 488 

207. Irregular articulation 488 

208. Inferior maxilla — showing angle at different ages 489 

209. Occipito-mental sling 490 

210. Corrected denture 491 

211. Ketaining plate 491 

212. Wedged denture 492 

213. Expanding screw 494 

214. Instruments employed in scaling teeth 503 

215. Denudation of teeth 505 

216. Denudation of teeth 505 

217. Salivary fistule , 508 

218. Operation for fistule 511 

219. Tonsil glands 516 

220. Hypertrophied tonsil 520 

221. Tonsillotome 523 

222. View of the air-tubes 527 

223. Uvula scissors 530 

224. "View of gums inflamed by vulcanite plate 543 

225. View of case of general hypertrophy of gums 545 

226. View of chronic ulitis, with recession 546 

227. Sequestrum after measles 582 

228. Appearance of patient with phosphor-necrosis 593 

229. Crossed and knotted bandage 600 

230. Barton's bandage, and jaw-fracture dressing 628 

231. Gibson's bandage 629 

232. Garretson's bandage 630 

233. Gunning's first splint 631 

234. Gunning's second splint 631 

B 



xviii LIST OF ILLUSTRATIONS. 

FIG. PAGE 

235. Gunning's third splint 632 

236. Gunning's fourth splint 632 

:237. Complete dislocation of jaw 637 

'238. Manipulations in dislocation 641 

239. Vertico-mental cap 642 

240. Superficial ranula — showing treatment by seton 699 

"241. Deep-seated ranula 700 

.242. Microscopic view of cancer-cells — after Paget 770 

:243. Amputation of tongue by strangulation 796 

.244. Transfixing ligature 797 

245. Chassaignac's ecraseur 798 

'246. Wire ecraseur 798 

247. Kegnoli's operation for ablation of tongue 799 

248. Syme's operation for ablation of tongue 799 

249. Epulic tumor 820 

250. Odonto-periosteal tumor 821 

251. Ulitic tumor 821 

•252. Epulic tumor 827 

'253. Epulic tumor ". 827 

254. Epulic tumor 827 

255. Epulic tumor 827 

256. Epulic tumor 827 

257. Operations on lower jaw 830 

258. Odontoma 835 

259. Odontoma 836 

260. Microscopic section of 836 

261. Hyperostosis 839 

262. Osseous tumor 842 

263. Hyperostosis of tuberosity of maxilla 843 

264. Microscopic section of. 845 

265. Odontocele 850 

266. Dentigerous tumor 856 

267. Microscopic section of 857 

268. Dentigerous tumor 859 

269. Dentigerous tumor 860 

270. Dentigerous tumor..... 861 

271. Microscopic section of 862 

272. Antral cyst 870 

273. Secondary cyst of antrum 872 

274. Osteo-sarcomatous tumor 894 

275. Cysto-sarcoma 894 

276. Nodulated tumors 907 

277. Hard cancer-cells 910 

278. Encephaloid tumor 915 

279. Encephaloid tumor 916 

280. Microscopic view of cells in soft cancer 916 

281. Cells seen in soft cancer 916 

282. Dotted nuclei of soft cancer 916 

283. Clustered nuclei of soft cancer 917 



LIST OF ILLUSTRATIONS. xix 

FIG. PAGE 

284. Caudate cells of firm encephaloma 917 

285. Small elongated cells of encephaloma 917 

286. Indurated epithelioma 918 

287. Ulcerating epithelioma 918 

288. Epithelioma of gum 919 

289. Sebaceous tumor of face 933 

290. Cartilaginous cysts 935 

291. Lobulated lipomatous tumor 936 

292. Microscopic structure of an adipose tumor 936 

293. Fatty tumor from under the tongue 936 

294. Yenous tumor 939 

295. Strangulated tumor on lip 940 

296. Transfixed tumor 941 

297. Transfixed tumor 941 

298. Keloid boa of neck 950 

299. Elliptical incision in the operation for hare-lip 957 

300. Hainsby's compress 960 

301. Hare-lip operation 963 

302. Hare-lip operation 964 

303. Double hare-lip 965 

304. Projection of intermaxillary bone 969 

305. Complicated hare-lip 970 

306. Complicated hare-lip 970 

307. Complicated hare-lip 970 

308. Complicated hare-lip 970 

309. Complicated hare-lip 971 

310. Hare-lip pins and ligatures 972 

311. Mouth-stretcher 978 

312. Study in lip operations 983 

313. Study in lip operations 985 

314. Study in lip operations. 985 

315. Study in lip operations 986 

316. Study in lip operations 986 

317. Study in lip operations 987 

318. Study in lip operations 988 

319. Study in lip operations 989 

320. Study in lip operations 989 

321. Study in lip operations 989 

322. Study in lip operations 990 

323. Plastic operation on face 992 

324. Study in rhinoplasty 1000 

325. Study in rhinoplasty 1001 

326. Study in rhinoplasty 1001 

327. Study in rhinoplasty 1001 

328. Study in rhinoplasty 1002 

329. Study in rhinoplasty .^. 1002 

330. Study in rhinoplasty 1006 

331. Study in rhinoplasty 1007 

332. Mouth gag 1029 



xx LIST OF ILLUSTRATIONS. 

FIG. PAGE 

338. Study in obturators 1037 

334. Study in obturators 1008 

335. Study in obturators 10-10 

336. Study in obturators 1041 

337. Study in obturators 1042 

338. Study in obturators 1043 

339. Study in obturators 1044 

340. Study in obturators 1045 

341. Study in obturators 1046 

342. Face without nose 1049 

343. Palatine arcb with obturator 1050 

344. Artificial nose 1052 

345. Attachment of artificial nose 1052 

346. Artificial nose in place 1053 

347. Face without nose and superior lip \U~. 

348. New-made lip 1056 

349. Artificial nose in place 1057 

350. Artificial nose, showing springs for retaining 1057 

351. Mouth-stretcher applied 1066 

352. Mouth-stretcher applied 1066 

353. Surgical anatomy of inferior maxillary nerve 1070 

354. Incision for exposing coronoid process of lower jaw 1071 



PLATES. 



I. Anomalies in dentition 157, 158 

II. Anomalies in dentition 160, 161 

III. Anomalies in dentition 163, 164 

IV. Dental tumors, with microscopic appearance of 166 

V. Anomalies in dentition 167, 169 

VI. A view of the anatomy of the side of the face and of some of 

the operations practiced on it 515 

VII. A view of operations performed on the trachea 531 

VIII. Appearance and position of some of the tumors seen about the neck 931 

IX. Hare-lip and atresia oris 972 

X. Plastic surgery of lips 972 

XII. Operations on the tongue 795 

XIII. Operations in rhinoplasty 999 

XIV. Khinoplastic and cheiloplastic operations 1003 

XV. Khinoplastic operations 1005 

XVI. The operation of staphyloraphy 1024 

XVII. Eesections of maxillse 1061 



STUDENT'S PREFACE. 



Special surgery, like surgery proper, considers and treats of dis- 
ease as contradistinctive to ease. 

Ease implies the normal condition. A body in a state of eas'e is 
in harmony, part with part, no source of derangement existing to 
interfere with its functional life. 

Dis-ease, in the greatest breadth, as in the narrowest, of its signi- 
fication, has its meaning in a single word, — "irritation." 

Irritation is that derangement, of any and every nature, which 
ensues from the presence of an irritant. 

An irritant is that which irritates, or which interferes with func- 
tion. What an irritant may be, — how it deranges, — how it inter- 
feres with ease, producing disease, — how we are to antagonize it 
and its results, — this is the province of the science we study. 

Imprimis : A student will look most simply, yet truthfully and 
fully, at. the subject-matter of our study, thus : Whenever a patient 
presents himself with his complaint, no matter what may be the 
character of the lesion, where or how situated, the trouble has its 
origin in the presence, directly or indirectly, of some agent of irri- 
tation. This appreciated, a deduction naturally follows, — that the 
relief and cure of disease should lie in the discovery and removal of 
a cause inducing it. 

An irritant is an offense of many aspects. It may be a simple 
splinter pricking the finger, easy of recognition and treatment, or it 
may be some adventitious deposit in a viscus, which the nicest 
refinement of modern diagnosis shall not enable us to discover. 

The study of medicine comprehends much. If it begins with the, 
splinter, it has its domain bounded alone by the widest investigations 
of physics. A surgeon is full, in proportion as he comprehends from 
the central principle outward. To pull a splinter from a wounded 
finger, to lift a mote from an eye irritated through its presence, — 

2 (17) 



18 STUDENTS PREFACE. 

these are surgical performances, simple, it is true, yet are applica- 
tions, in such direction, of knowledge We may pass outward to the 
inflamed jaw which the carious tooth worries and frets by its pres- 
ence, and, with the comprehension of an effect from a cause, extract 
the offending organ, and from his dis-ease the patient is immediately 
restored to ease. We find a bone necrosed, and are instruments of 
good to a sufferer so far as our attainments shall direct in the means 
to his relief. We meet with an arm or a leg fractured, and as we shall 
comprehend the meaning of such accident in its relation with the 
laws of the human organism, so we restore the member to useful- 
ness, or complete its destruction. 

From evident causes of disease an observer finds himself led to 
an appreciation and judgment of the occult and complicated. Judg- 
ment grows an offspring from knowledge, and becomes a power as 
reliable as that which has emanated it ; thus, through the seen, is 
the unseen not unfrequently to be recognized. 

When the body is in a state of ease, we say it is in a physiolog-ical 
state ; when in dis-ease, we pronounce the pathological condition. 
Pathology is a study having its basis in physiology, and physiology 
is a science having its foundation in anatomy. The animal body is 
a machine. To comprehend a machine, one must analyze it, — take 
it apart, look into and recognize piece by piece its construction, 
know where this and that fit, and what is the harmony of the asso- 
ciation. This is anatomy. A man may never be a surgeon, gen- 
eral or special, who begins not with such analysis as his foundation. 

A knowledge of the construction of a machine enables one to under- 
stand the principles and nature of the movements pertaining to the 
construction, let these be what they may. That which is the life — 
the movement — of a machine, is its physiology : one may scarcely be 
expected to possess the ability to appreciate the wrong-going of a 
machine who knows not what is the right-going of it. Physiology, 
then, is, to the surgeon, a preliminary study, succeeding, with him, 
Anatomy. 

Pathology is the expression of Irritation ; irritation we recognize 
as the signification of disease. Having familiarized himself with 
the anatomy and physiology of a human being, a student is prepared 
to appreciate collectively, in association, or distinctively, any fact or 
facts presented to him in surgery. 

By Irritation, we have understood an effect which follows from the 
presence of an irritant. The sources and causes of irritation a 



STUDENT'S PREFACE. 19 

writer might scarcely attempt to enumerate. Food, which to-day 
digests and nourishes, to-morrow ferments and poisons ; the glisten- 
ing stone, which in the morning the child delights to show its play- 
mates, in the afternoon kills its owner by falling into his windpipe ; 
water refreshes, or it may scald or drown ; sunshine affords life, 
or burns and depresses to death ; years grow vigor and breed 
debility. We may fairly embrace this aspect of our subject only by 
recognizing that there is nothing which is incapable of becoming a 
source of irritation. As the reflection of part upon part is concerned, 
we instance the deranged stomach, the congested liver, the parasite- 
loaded bowel, the stone in the bladder, the calculus' in the kidney, 
the tumor over the nerve. 

The phenomena, however, which designate and characterize the 
presence of an irritant, — these we are to comprehend and appre- 
ciate. 

The presence of a source of irritation finds primary expression in 
a disorder of sensation ; such disorder being of an extent and char- 
acter corresponding with the nature of the offending agent, or the 
idiosyncrasy of the individual. Disordered sensation may be gen- 
eral or local : shock, from the reception of sudden tidings, illustrates 
the first ; the tingling half-frozen fingers are an example of the 
second. Disordered sensation may be attended or unattended with 
the feeling of pain ; pain in disordered sensation originates in me- 
chanical pressure or other source of offense arising from the lesion. 

Evidences of irritation are, in their relationship, direct or indirect. 
An aching tooth may express itself by a neuralgia seated in the dura 
mater, or on any branch of the trigeminus ; a worried liver may 
speak its complaint in the subscapular branches of the cervical 
plexus ; a gorged stomach will not unfrequently look its distress 
from an enlarged and fixed pupil. 

The effects of an irritant acting upon a part are apt to have a 
history modified by the temperament, or state of force, of the indi- 
vidual. A blow received by a delicate woman upon the lower jaw, 
breaks, perhaps, that bone ; received by the scrofulous child, it inr 
flames and kills the part; the same force of offense to a vigorous 
farm-laborer scarcely elicits recognition. Phosphorus, while utterly 
destructive to the bone of one workman in the match-factory, is fully 
resisted by his fellow laboring at a neighboring table. A single 
carious tooth in the jaw of one person may provoke necrosis ; in 
another, a mouthful similarly affected fails of such an end. The 
slightest extent of irritation may suffice, in the plethoric, to excite 



20 STUD EXT S PREFACE. 

an inflammation ; in the lymphatic man it takes a very great amount 
to elicit from the sanguineous system even a response. In the case 
of the non-cognizable irritants, as the epidemic, endemic, and infec- 
tious poisons, such modification finds most marked illustration. One 
individual shall be so susceptible as to succumb without resistance; 
a second finds his system offering long-continued battle ; a third 
seems not at all susceptible. We are to infer, then, that the evi- 
dences of the presence of an irritant have a much modified expres- 
sion. 

"We pass here to the observation of the common expressions; and, 
that we shall possess an illustration recognizable by any student, 
we consider, first, the simple mechanical irritant. 

A man, for example, receives a shot in his body. Here, as the 
primary condition, there is a break of continuity in the tissues, asso- 
ciated with more or less injury. How will the system endure and 
treat this offense ? First, recognition is received by the sensorium 
through the medium of the injured sensory nerve-filaments; pain is 
felt, and functions are interfered with according to the extent and na- 
ture of the injury. The sensorium, immediately responsive, issues 
directions for the expulsion of the offending agent ; the means to this 
end is to be the loosening of the body and the floating of it from its 
lodgment, This applies to every description of foreign substance, 
whether it has come from without, or should develop within, as in 
the case of dead bone or calculi. First, it is perceived that neigh- 
boring parts increase in redness. This is the result of a superflow 
of blood to the parts. It is termed, technically, "simple vascular 
excitement.'" This flow increases, until at length every vessel be- 
comes engorged. This is the state of "congestion." A succeeding 
stage is the stoppage of this mass of blood, — "stagnation." Nu- 
trition now ceases, the parts die, and, in a stream of pus " suppura- 
tion," the agent of the offense and its immediate envelope are floated 
away. Thus, Nature has relieved herself, and, the process of repair 
taking the place of the destructive process, the lost part may be 
quickly restored. 

The action thus hastily described is, however, a rule with excep- 
tions. A foreign body may become encysted, — that is. Nature may 
find her easiest and quickest relief by enveloping the offense in a 
cyst, and, while affording it lodgment, yet shut it out from all rela- 
tionship with the life surrounding it. As examples of such relief, 
cases are on record of balls remaining without discomfort in the 
human bodv for vears. 



STUDENTS PREFACE. 21 

The presence of a foreign body may be tolerated through other 
natural provisions. Thus, a calculus forming in a duct may have 
such duct enlarge the provisions of its carrying capacity so that the 
body shall not complete an obstruction. Illustrations of this pro- 
vision exist in the case of gall and salivary obstructions. A stone 
in the bladder will excite that extent of vascularity which shall 
overbalance the mechanical attenuation and thinning through a 
resulting hypertrophy, thus antagonizing the destructive influence. 

A foreign body may be cast out through the offices of a functional 
activity excited in the parts invaded: the lachrymal secretion wash- 
ing a particle from the eye furnishes an illustration. 

Irritation, when existing as an element in the process of the 
expulsion of an offending body, is classible as the first of the inflam- 
matory phenomena. Thus, we study inflammation under six asso- 
ciated aspects : 

1. Irritation. 

2. Simple vascular excitement. 

3. Active congestion. 

4. Stagnation. 

5. Suppuration. 

6. Repair. 

The associate characteristics by which we distinguish the existence 
of inflammation are redness, heat, pain, swelling, and granular activity. 

The study of inflammation is the completion of the circle of the 
meaning of irritation. No man may know of surgery but as he 
knows of inflammation. 

General irritation. — Viewed from the medical stand-point, we are 
to assume the existence within the human system of a force which 
we term excitability. Of this force we affirm, as of the blood, 
that there is just so much, and, like unto the blood, that it is 
harmonious and proportionable in its disposition. This excita- 
bility, vis vitse, is a correlating essence or thing, and is consequently 
to be considered as allied with matter. The correlating of this vis 
vitde differs in no respect, save in manner, from the principle employed 
in converting heat into steam, and steam into momentum, and mo- 
mentum back again into heat ; and the life itself differs not in kind 
from that which is the cohesive force of a weed. 

Physical life is a phenomenon, — this, and nothing more. What, 
from lack of better understanding, we term the vis vitse, is to have 
from us no more respect, nor is it, as the physician is to estimate 



22 STUDENTS PBEFACE. 

it, less an anatomico-physiological thing, than is a bone, a muscle, 
or a brain-cell. As physicists, we consider it physiologically, and 
through such consideration we direct and circumvent its vagaries as 
we do that of the blood in its associative inflammatory perversions.* 

Excitability we are to accept as the vivifying principle. As this 
force exists in a correlative fullness, man lives ; as it diminishes in 
him, so he proportionably dies. Ample illustration of such truth 
exists in the matter proper, as we recognize it, of the body. In what 
we term the physiological state we find the act of life-renewal a per- 
fect process ; the organism is maintained in its integrity. In sick- 
ness, correlation is deranged, the circle is broken, and that matter 
which is constantly passing from the body is not replaced by that 
which in the normal life is constantly coming to it; hence the wast- 
ing, — the decrease. It is the classic legend of the pelican constantly 
repeating itself, — the bird feeding its offspring with its own body, 
having in its turn no nourishment. 

Excitability — i.e. the vis vitse, the vitalizing principle — is not to 
be confounded with nerve-matter, or with the sanguineous system, 
or with any special relation. It is Force : a something in itself, — in 
abstracto. Xegatively, we recognize it in its going out from organic 
tissue. First, its existence in the muscular sense, say of a living 
bullock : then its complete absence in flesh which is called putres- 
cent. In the meat of the shambles we see that extent, relation, and 
conjunctive quantity of it which is the mean between that which 
pertains to moving life and disintegrative death. In other words, 
we see in the meat the relation between force and matter, in that the 
law of the transformations and transmigrations of the one is the 
common law of both. 

The treatment of disturbance of excitability through nervines 
finds its explanation, I conceive, in a deadening impression made on 
the instruments of its expression ; as, for example, in the sanguineous 
system we may, through the application of ether-spray or other 
means of cold, so contract the capillaries of a part that, in defiance 
of the most urgent protest of a fever-irritated heart, we utterly abro- 
gate the office of these vessels, and, so far as the parts are concerned, 
deny, ipso facto, the power to the organ of expression. 

Accepting, then, the premises of the existence of excitability, 

* The author denies a right to criticise this passage except to him who 
recognizes a distinction assumed between the Ego and the physical man. 



STUDENTS PREFACE. 23 

without a present consideration or speculation as to what it is, we 
find our first expression of systemic irritation in the perversion of 
the equilibrium of this something. General irritation is super- 
excitation. It has been maintained that as the body contains just 
so much excitability, and that this expresses fullness, there cannot 
be such a thing as general excitation ; but this is certainly a fallacy, 
for as well might we say that the oceans of water could not be roused 
from their normal calm and lashed into rolling waves. It does not 
seem at all necessary to fall back on the premise that, although the 
system has such limited amount of excitability, the full force of it is 
not called into play in health, and that general irritability means the 
provocation into action of the reserve. In fever, the circulation is 
in a state of general disturbance or irritability, and of this fluid there 
is in a body just so (proportionable) much ; but here we are not at 
fault in reading the phenomenon ; only, however, are we not so, 
because we deal with a cognizable thing. 

That excitability uses primarily the nervous system as the instru- 
ment of its expression seems fully demonstrated in such metastatic 
transfers of inflammatory phenomena as are found in the relation 
of parotitis and orchitis; while a negative proof, having the wide 
signification of exhibiting the comparative separability of the Ego 
from the common life of a man, is seen in the exemption of the nerves 
of special sense from the uses of organic life. To make an example: 
we may so benumb the fingers that incisions can be made without 
pain, yet during the process find the special sense of touch unim- 
paired ; or we may make another demonstration in witnessing the 
painless cutting, lacerating, or burning of a nerve of special sense 
while beholding the writhings which attend the wounding of a part 
supplied from the excito-motor system. 

Recognizing thus the existence of a common life-principle and its 
subjectiveness to general super-excitation, we are prepared to pass, 
with sounder judgment, to the expressions of irritability as mani- 
fested in its employment of the resources of the sanguineous system 
in the perversions known as inflammatory. 

Fever, the expression of general excitability, seems to partake of 
the nature of a reactive process ; preceded by depression so great, it 
may be, as to amount to chill; its division into the three stages of 
invasion, reaction, and resolution are commonly very marked. 

Invasion. — This maybe characterized by a distinct chill or shiver- 
ing fit, or may be confined to general malaise, the pulse being 
depressed, the appetite defective, with indifference to food, and, it 



24 STUDENTS PREFACE. 

rnay be, nausea ; the surface of the body marks a diminished tem- 
perature, and is not unfrequently shriveled, presenting the peculiar 
roughness known as the cutis anserina This state of depression 
may exist from a few hours to several days. 

Reaction. — The second condition is marked by increase of pulse, 
with heat that soon grows into a sense of general flush ; appetite 
still further diminishes ; the tongue most likely becomes furred ; the 
bowels are constipated ; thirst grows a prominent symptom ; the tem- 
perature naturally finds an elevation from the increasing rapidity of 
circulation and cell-change, the pulse running up not unfrequently 
as high as 110°. The overexcited brain, unable to perform its 
functions, deranges more or less all expressions of which it is the 
instrument; taste is disagreeable, or, it may be, is lost; the senses 
of seeing and hearing grow preternaturally sensitive ; in short, up 
to a certain point — the point of exhaustion — the system at large 
manifests the condition of super-excitation. It is the quiet of water 
disturbed by the storm. 

Declining stage. — In fever, disassociated with organic derange- 
ment, — that is, in the " ferveo" of simple super-excitation of the vis 
vitse, — the return to the equilibrium is gradual and without the 
marked phenomenon of a crisis. The sense of heat passes away 
gradually, thirst diminishes, the skin relaxes, the secretions restore 
themselves, and in a greater or lesser length of time, depending on 
the temperament of the individual, the harmony of functional life is 
restored. It is the disturbed water recovering its calm. 

General Remarks. 
Fever is always to be looked on as disturbance of the vitalizing 
■ principle. A fevered patient is in a condition analogous to a burn- 
ing candle variously disturbed by excess of carbon or oxygen ; 
both the one and the other influence aside from the mean. Depres- 
sion or super-excitation may exist within the limit of non-functional 
disturbance, thus demonstrating the ability of organic life to endure 
without ill result a certain extent of trespass. The state of invasion 
of fever is to be viewed as that condition in which the vis vitse is 
restrained. Reaction is that stage in which, overflowing or break- 
ing such restraint, accumulation exhibits itself in consequent super- 
excitation. 

Irritation is, or is not, the first of the inflammatory phenomena 
(locally expressed), according as it is, or is not, followed by perver- 
sion of the circulatory system. When irritation has excited vascular 



STUDENT'S PREFACE. 25 

derangement, then the term is merged into the varying terms ex- 
pressive of the stages of inflammatory action. Inflammation is not 
a general, but a local condition, and its normal history is that which 
tends to the relief of irritation through the expulsion or destruction 
of a cause inducing it, as is illustrated in the process of suppuration. 
Fever and inflammation, as thus exhibited, are not to be esteemed 
necessarily coexisting phenomena. Fever commonly associates itself 
with inflammation, being aroused by such condition acting as an 
irritant, while, in turn, febrile disturbance may readily provoke an 
inflammation through its excitation of the circulatory system ; but 
it is frequently enough to be remarked that fever, even of severe 
grade, may readily run its course without inducing that extent of 
vascular perversion which yields the phenomenal expression of in- 
flammation. 



DISEASES OF THE MOUTH 



ASSOCIATE PARTS. 



CHAPTER I. 

SURGTCAL ANATOMY OF THE MOUTH AND FACE. 

Beginning with this first chapter, the author assumes a famili- 
arity on the part of his reader with the principles underlying general 
medical practice, allusion to which hasjustbeen made, — a familiarity 
which is alone able to render intelligible, useful, or desirable the 
study of any one of its specialties. 

In a work on oral diseases and surgery, a source of ready and 
accurate reference to parts involved would seem to be an essential. 
With such view we map out, as accurately as the photograph and 
pencil may represent nature, all such parts as, surgically, we may 
have to deal with or comprehend. As — unless with the very expe- 
rienced — it is always desirable to precede an operation on the living 
with a test performance on the dead, so with the student it is as 
desirable to found the comprehension of any pathological perversion 
on an understanding of normal characteristics. 

In presenting these photographs of the various parts associated 
with oral surgery, the suggestion may be added, that the bones rep- 
resented be procured and laid carefully away in the cabinet: the 
assistance of their silent expressions will be found invaluable. So 
far as the soft parts are concerned, one may either possess them in 
alcohol, or, what is even better, where it can conveniently be done, 
may make it a point to dissect them yearly. 

Fig. 1 (exhibited on page 30) represents the lateral aspect of 
the face ; this is seen to form, almost accurately, an oblong square. 
A modification on such a square, however, will be found to exist 
in the case of the child, where the ramus of the inferior maxil- 
lary bone is at a more obtuse angle with the body; also in the 
case of an adult with prominent os frontis: in either of these cases 
this aspect is triangular. Bounded circumferentially by the supra- 
orbital ridge of the frontal bone, the nasal process of the superior 
maxillary, and the malar bones, we find a pyramidal cavity, the 

(29) 



30 ORAL DISEASES AND SURGERY. 

orbital, for the accommodation of the organ of sight. Looking at 
the natural bone, no less than seven pieces are observed entering 

Fig. 1. — Front and Lateral Kegion of the Skull. 




The skull, seen partly in front and on the right side. 1, frontal bone ; 2, parietal 
bone; 3, temporal bone, its squamous portion; ■i, tbe sphenoid bone, temporal surface of 
its great wing; 5, ethmoid bone, its orbital surface; 6, superior maxillary bone ; 7, malar 
bone : 8, lachrymal bone ; 9, nasal bone ; 10, inferior maxillary bone, a, orbital plate of 
the frontal bone; b, temporal surface; c, orbital surface of the great wing of the sphenoid 
bone; d, mastoid portion of the temporal bone; e, orbital surface of the malar bone; 
/, orbital plate of the superior maxillary bone ; g, infraorbital foramen ; h, mental fora- 
men; i, symphysis; j, ramus; k, coronoid process; I, neck supporting the condyle; m, 
angle ; n, lachrymo-nasal duct. 

into the composition of this cavity, some of which pieces in their 
relations closely affect proceedings in oral surgery: for example, it 
will be seen that a large portion of the floor of this cavity is made 
up by a process, the orbital, which is a part of the superior maxilla ; 
glancing at a disarticulated bone, it will be seen that this process 
constitutes as well the roof of the antral sinus; it will also be 
found to be a very thin plate, and capable of being easily elevated 
or depressed, according as any pressure might be brought upon it 
from below or above ; constituting a source of support to the eye, it 
will also be seen that, where it is possible, it should be left undis- 
turbed in operations demanding extensive interference with the bone 
of which it is a part. At the inner inferior aspect of the cavity a 
groove will be observed, the lachrymal, being the entrance to a canal, 



ANATOMY OF THE MOUTH AND FACE. 31 

the ductus ad nasurn, carrying the tears from the orbit to the inferior 
meatus; the outer wall of this canal, which it is most important to 
maintain patulous, is made up by the inner face of the nasal process, 
another portion of the superior maxillary bone. Diseases of the sinus 
not unfrequently react on the eye, and to such an extent, that blind- 
ness of several months' standing has been cured by the extraction 
of a diseased tooth-root which had affected the antrum to its engorge- 
ment. Closure of the lachrymal canal is almost certain to occur if 
the nasal process becomes inflamed, and such inflammation I have 
frequently met with as the result of an odontocele. 

Immediately below the inferior boundary of the orbit is seen a 
foramen, the infraorbital, for transmission of the infraorbital branches 
of the fifth nerve. Passing a bristle through this foramen, it is seen 
to emerge in the groove marked on the floor of the orbit, — the infra- 
orbital groove in which the nerve lies in its passage outward. This 
groove and this canal are both in the maxillary bone, and are, alike 
with the ductus ad nasum, influenced by its diseases. 

The canine fossa, seen back of and above the canine tooth, has, as 
its floor, a thin plate of bone, which is the external face of the antrum, 
and through which, if it should be found necessary, the cavity may 
be easily entered. 

The tuberosity of the bone, occupied in part by the wisdom tooth, 
and marked for the attachment of the buccinator muscle, is a point 
of surgical interest, — it being not at all uncommon to have necrosis 
of this portion of the bone, the result of an ostitis, induced and kept 
up by an imprisoned dens sapientiae. Standing, as is seen, at an 
angle, and tubercle-like, it is plainly evident that neither deformity 
nor harm would result from its separation as a sequestrum. 

The alveolar processes are remarked to constitute quite a large 
part of both the superior and inferior maxillary bones. These pro- 
cesses, vascular and spongy, subjected to all irritations residing in 
diseased teeth, are, without doubt, more liable to take on patho- 
logical action than any other portion of the ossa corpora?. From 
the alveolo-dental periosteum spring epulic outgrowths of various 
signification. Sarcomatous degeneration finds here a favorite seat: 
simple and compound cysts are very familiar ; degenerative ostitis 
is not uncommon, while abscess is found in almost every mouth. 
The mental foramen, seen upon the inferior maxilla, a little anterior 
to the middle of the body, is the outlet of a canal traversing the 
centre of the bone, and conducting beneath the teeth the dental 
artery and nerve. The size, general character, and inlet of this 



32 ORAL DISEASES AND SURGERY. 

canal should be observed, as not unfrequently injuries to the artery 
require that the canal should be plugged, either as foramina are 
concerned which exist beneath each tooth, or as the channel proper 
is interfered with in operations for tumors or sequestra. 

Neuralgia of some of the peripheries of the inferior dental nerve 
makes necessary, occasionally, its section within the canal. To get 
at this nerve, requires either that we shall extract some tooth, and 
make the section from the base of the socket, or otherwise that a 
trephine shall be used from the outside. The easiest mode of per- 
forming such operations is to be observed, as relation is had to 
location, and character of the bone. 

The association of the teeth with their spongy processes is a mat- 
ter which should receive close attention, the operation for their 
extraction being a very common one. These processes, if examined 
in a number of bones, will be found to vary greatly in character: in 
some being of such loose structure that the teeth are capable of the 
easiest separation ; in other instances being so firm and unyielding 
that it is quite an impossibility to make such extraction without 
more or less fracture. 

The number and shape of the roots of the teeth are to be ex- 
amined. A knowledge of their curves contributes much to skill in 
their removal. Indeed, no one but the experienced can appreciate 
how much easier it is to remove the teeth with than without such 
knowledge. 

The nasal bones, forming in their conjunction the nasal arch, 
should be examined in their relation to each other and to neigh- 
boring pieces. Articulating with the perpendicular plate of the 
ethmoid, it has not unfrequently happened that the depression of 
this arch from a blow has carried the crista galli into the sub- 
stance of the brain, and thus produced fatal consequences. The 
nasal bones are frequently the seat of syphilitic degeneration. Their 
destruction compels the falling in of the nasal arch, thus yielding the 
flattening of the bridge occasionally observed, — one of the most 
repulsive of deformities. 

The incisive fossa, observed between the anterior nasal spine and 
central incisor teeth, frequently yields its floor to the ravages of 
necrosis or caries. There would seem to be here less vital resistance 
than in other parts of the bone, as necrosis of a tooth is almost 
necessarily associated with disease of the superficial surface of its 
alveolus. This plate is, however, quite thin, and its loss seldom 
seems of much consequence. 



ANATOMY OF THE MOUTH AND FACE. 



33 



The position of the groove for the passage of the facial artery, 
seen on the inferior maxilla, is to be noticed, as location and dis- 
tance from the angle of the jaw are concerned, — the control of 
hemorrhage about the lips and cheeks being here secured through 
simple pressure on the artery as it passes over the base. 

With such general observation of the surgical features of the 
bones in conjunction, we pass to a closer study, by examining the 
pieces in their separate capacities. 



Figs. 2 and 3. — Superior Maxillary Bone. 

(8 




Superior maxillary bone of the left side, 
outer view. 1, body ; 2, tuberosity ; 3, alve- 
olar border; 4, orbital plate ; 5, nasal process ; 
6, nasal notcb ; 7, nasal spine ; 8, lachrymal 
groove ; 9, entrance of the infraorbital canal ; 
10, infraorbital foramen; 11, orifices of the 
posterior dental canals ; 12, malar process ; 
13, articulation for the internal angular pro- 
cess of the frontal bone ; 14, incisor teeth ; 
15, canine tooth ; 16, premolar teeth ; 17, large 
molar teeth. 




Superior maxillary bone of the left side,. 
inner view. 1, nasal surface of the body ; 2, 
surface for the palate bone; 3, alveolar bor- 
der ; 4, orbital plate ; 5, nasal process ; 6, 
ridge for the articulation of the turbinated! 
bone; 7, nasal spine; 8, groove contributing 
to form the lachrymo-nasal duct; 9, maxil- 
lary sinus; 10, palate plate, its articulating, 
border for the right maxillary bone ; 11, in- 
cisive foramen continuous with the naso- 
palatine canals ; 12, tuberosity ; 13, articular 
extremity for the internal angular process 
of the frontal bone ; 14, incisor teeth ; 15, . 
canine tooth; 16, premolar teeth; 17, large 
molar teeth. 



Glancing hastily at the superior maxillary bone, it seems like 
a quadrilateral, more or less irregular, solid piece. Looking at it 
critically, and from the surgical stand-point, we find it to consist of a 
series of processes, so grouped together as to form, or rather inclose,. 
a cavity so large that the apparently solid body is found to be 
simply a shell. This cavity of the shell is called the maxillary 
sinus, or the antrum of Highraore. It is a very irregular cavity,, 
differing, indeed, in shape in almost every bone ; generally, how- 

3 



34 ORAL DISEASES AND SURGERY. 

ever, being found as a single cave, but not unfrequently divided into 
two or more by septi of bone vertically placed. How far, in the 
mean of cases, the cave is found to run forward and how far back- 
ward ; what, in the mean, is its relation to the roots of the various 
teeth; which of its boundaries are the thinnest; are matters which, 
because of their very practical signification, are worthy of being most 
attentively studied, and which study can only be made by an observa- 
tion of many bones. Abscesses of the roots of teeth frequently void 
themselves into this cavity : we are to understand how and why, 
anatomically, such accidents occur. Engorgements of the cavity, 
puruloid or dropsical, bulge outward some part or other of the 
circumferential walls, perhaps throwing the eye upon the cheek, 
projecting the canine fossa, or making a tumor on the palatine 
aspect of the mouth: we are to understand why such bulging, from 
a common cause, is found so variously situated, or why, indeed, 
such accumulations exist at all. 

If we make such a section of the superior maxillary bone as to 
expose the antral cavity, we shall find that in many cases, not in- 
deed in all, its floor is studded with little hills; break into one of 
these elevations, and you will find that it is a very thin crust, con- 
cealing the root of some tooth or teeth. In infrequent cases, a root 
or roots will be found projecting into the cavity, entirely uncovered, 
save with the membrane which had existence in the living part. Such 
a view explains very satisfactorily dental abscess within this sinus. 

The processes which, in their conjunction, make up the bone, are 
four in number : the alveolar, the palatine, the nasal, and the malar. 

The alveolar process, wedged in between the malar and palatine, 
constitutes perhaps the greatest bulk of the bone. Looked at from 
below, it is found to be excavated into cavities or pits, correspond- 
ing with the character and number of the roots of the teeth ; these 
pits are termed alveoli, and, in the recent bone, are found lined with 
periosteal tissue, which tissue is reflected around the roots of the 
teeth, forming the immediate bond of connection. In some bones, 
the structure making up this process is exceedingly loose and spongy ; 
in others it is condensed, and cortical-like. After the loss of the teeth, 
this process is removed through absorption ; hence the approximation, 
in old people, of the chin and nose. Fractures of this process, the re- 
sult of falls, blows, or attempts at tooth-extraction, are quite common. 

The tuberosity of the bone may be esteemed as the posterior ex- 
tremity of the alveolar process, being, indeed, not unfrequently 
excavated for the wisdom tooth. This tubercle, as implied in its 



ANATOMY OF THE MOUTH AND FACE. 35 

name, is simply a bulb of bone ; it is quite vascular, however, and 
its relation to the posterior tooth subjects it to sources of irritation 
which not uufrequently results in its inflammation and death. 

The malar process, seen projecting from the middle of the bone, 
is a rough, serrated facet for articulation with the malar or cheek 
bone. This process, in front, is somewhat concave ; behind it has 
similar curvature, and forms part of a fossa known as the zygo- 
matic. The chief point of interest connected with it, however, lies 
in the character of the suture which unites the maxillary with the 
malar bone, this being the place of separation in amputation of the 
maxillary. 

The nasal process, well represented in the drawing, but better 
studied and understood from observation of the bone, is observed 
standing above the orbital surface. Rising from the anterior facial 
aspect, it continues upward and somewhat backward, until it 
ends in a rough facet, which articulates the bone with the frontal 
and ethmoid, and assists in closing in the anterior ethmoidal 
cells. Lined in the recent state with the Schneiderian membrane, 
which membrane is continued into the cells of the ethmoid and 
frontal bones, a moment's reflection recognizes the meaning of that 
sense of fullness so common about the anterior base of the cranium, 
when inflammation and congestion exist in the nasal canals. Ex- 
ternally, the face of the process is concave, thus assisting in carrying 
out the natural curve of the lateral aspect of the nose ; numerous 
foramina are also observed on this face, for the passage of vessels. 
The tendo oculi has its attachment on this surface, while near, on 
the same plane, is a line giving origin to the levator labii superior 
alseque nasi and orbicularis palpebrarum muscles. Anteriorly, the 
border of the process is thin, and serrated for articulation with the 
nasal bone. Posteriorly, it is thick, and hollowed into a groove for 
the lodgment of the lachrymal sac and duct. When in position, in 
the articulated skull, this groove is converted into a canal by annex- 
ation with the lachrymal bone ; the canal, traced downward, is found 
to have somewhat of an hour-glass shape, being considerably con- 
tracted in the centre, and finally terminating at the inferior meatus 
in a bell-shaped opening. A little tubercle, the lachrymal, is seen 
where the anterior lip of the groove joins the orbital surface; this is 
a guide, directing the bistoury of the surgeon into the canal, when 
operations for its stricture are demanded. 

The orbital surface of the bone, seen before in its articulative 
position, is here observed separate ; falling at an almost direct right 



36 ORAL DISEASES AND SURGERY. 

angle from the facial aspect of the bone, it is remarked by such rela- 
tion to form a large part of the floor of the orbital cavity ; while looked 
at from the cave of Highmore, it is seen to form as well the roof of 
this vault. When broken, or held against the light, it is found to be 
almost a scale in thinness. The infraorbital ridge is simply the rim 
made by the bending downward of this orbital surface. Running 
along the free edge are observed three distinct articular faces : the 
outer, for the palate bone, the two inner for the orbital or plane plate 
of the ethmoid and lachrymal bones. Below the rim, or infraorbital 
border, is seen the orbital foramen. Passing a bristle into this 
opening, we find it directed to the groove on the orbital face, the 
intraorbital. Passing the bristle now from the groove toward the 
foramen, we find it may take some other track, and not appear at 
the opening. Searching for an explanation, we find the groove, soon 
after entering beneath the ridge, to divide into two canals, one of 
which passes to the face, as observed; the other enters the antrum, 
and transmits across this cavity the nerves and vessels designed for 
the nutrition of the anterior teeth. 

The osseous boundary of the nose is seen to advantage in this 
drawing. It is a complete curve, and gives attachment by its 
continuous crest, or edge, to the cartilaginous wings. 

The zygomatic surface, seen back of the malar process, enters into 
the formation of the fossa of that name. It is to a degree convex, 
and more or less rough. Dotting its surface are observed a number 
of foramina; these are entrances to canals, the posterior dental, 
and transmit vessels to the posterior teeth, all situated back of the 
canines. At the lower part of this surface, to the nasal aspect of the 
tuberosity, is a groove destined to be converted into a canal through 
an articulation with the palate bone, the posterior dental groove. 
This groove or canal transmits vessels to the palatine face of the 
bone, and is seen to terminate on the under side of the tuberosity. 

The muscles of expression, to which the outer surface of the bone 
gives origin, are numerous. From the second bicuspid tooth back 
to the tuberosity, is a rough line for the trumpeter's, or buccinator 
(a similar line existing on the inferior maxilla). Above this first 
line, and below the malar process, certain fibres of the masseter are 
attached. Above the canine fossa is the origin of the levator anguli 
oris ; while without this, toward the concavity of the nose, is the line 
for the compressor naris. In the incisive or myrtiform fossa is seen 
the origin of the depressor alas nasi. 

Turning now toward us the inner face of the bone, we see the 



ANATOMY OF THE MOUTH AND FACE. 37 

fourth process, the palatine. This process starts out from the middle 
of the bone, and divides it into two unequal parts. Like the orbital 
plate, it is at right angles with the body, and, when the piece is 
articulated, is seen to divide the nose from the mouth, constituting 
the floor of the first cavity and the roof of the second. Posteriorly, 
it is quite thin, and articulates with the palatine process of the palate 
bone. Running forward, it grows thicker and heavier, and ends in 
the anterior nasal spine. Viewed above, its surface is slightly con- 
cave, to form the floor of the nares. Externally, it becomes merged 
into the body of the bone; internally or mesially, it rises into a 
ridge, which is the one side of a groove receiving into articula- 
tion the vomer. A bristle passed through an opening in the pro- 
cess shows the position of a canal, the anterior palatine, transmitting 
vessels of that name, which find entrance into the oral cavity through 
the incisive foramen seen just back of the centre tooth. A nerve, the 
naso-palatine, having considerable surgical signification, enters the 
mouth at the orifice of this canal, but is not transmitted by it, 
having a canal of its own in the intermaxillary suture. The three 
marked points of surgical interest in this process are — first, the fact 
of its forming the boundary between the mouth and nose ; a break 
in its continuity, and which, unfortunately, is a not infrequent acci- 
dent, throwing these two cavities into one; second, the nature and 
relation of suture with the palatine process of the palate bone, this 
being the line of separation in amputation; third, the position of 
entrance of the naso-palatine nerve, paralysis of the parts supplied 
by this nerve being a frequent result of ill-applied pieces of dental 
apparatus. To these three might be added a fourth, the position of 
the artery occupying the posterior palatine canal, an artery which 
is sometimes of considerable size, and which might easily be cut by 
the slip of a lancet applied to the gum of a wisdom tooth, or in the 
act of dividing the tendon of the flexor palati where it curves around 
the ham alar process. 

The other features observable on this aspect of the bone are with- 
out special surgical interest. Above the inferior meatus, which is 
the space between the floor of the nares and the inferior turbinated 
bone, is seen the crest of attachment for this scroll. Still higher, 
on the nasal process, are the crests for union with the superior and 
middle scrolls. The middle meatus, into which opens the antrum, 
is observed to be quite a large space, particularly when compared 
with the superior meatus, which is the slit lying between the upper 
and middle crests. The opening of the antrum, seen in the back 



38 



ORAL DISEASES AND SURGERY. 



part of the middle meatus, is here portrayed of a natural size— that 
is, natural to the disarticulated bone. It will be remembered, how- 
ever, that it is filled in by other bones, which, in the articulated 
skull, reduce the opening to an outlet not larger than an ordinary 
probe ; the bones closing in this cavity are the ethmoid, palate, and 
inferior turbinated. (See descriptions of these bones.) 

The superior maxillary bone articulates with nine others : by its 
nasal crest with the frontal, ethmoid, lachrymal, and nasal'; by its 
malar process with the malar ; at the intermaxillary suture with the 
opposite maxilla; by its palatine process with the palate and vomer, 
and at the lower of the lateral crests with the inferior turbinated bone. 

Nine muscles have their origin from this bone : the orbicularis 
palpebrarum, the inferior oblique of orbit, the elevator of superior 
lip and wing of nose, the proper elevator of lip, the angular eleva- 
tor, the compressor naris, the depressor of the ala, the masseter, and 
the buccinator. 

INFERIOR MAXILLARY BOjSTE. 

The inferior maxillary bone, the largest and strongest bone of the 
face, consists of a body, horseshoe in shape, and of two rami, joined 
to the body at right angles. The body, which is the anterior 
portion, is surmounted by a process of more or less spongy bone, 
excavated for the reception of the teeth ; the basement portion, or 



Fig. 4. — Interior Maxillary Bone. 




1, body; 2, ramus; 3, symphysis; 4, base; 5, angle; 6, mental foramen; 7, condyle; 8, 
coronoid process ; 9, semilunar notch ; 10, inferior dental foramen, the entrance of the 
corresponding canal; 11, alveolar border; 12, incisor teeth; 13, canine tooth; 14, pre- 
molars; 15, large molars. 

that portion beneath the spongy series of cells, or alveolar process, 
is made up of very dense structure, and so hard and resisting as to 
be able to withstand very considerable blows. The rami, curved 
and angular at the base, terminate above in two processes : the 



ANATOMY OF THE MOUTH AND FACE. 39 

condyloid, for articulation with the glenoid cavity in the temporal 
bone, and the coronoid, for the attachment of the temporal muscle. 
The angle of relation of the perpendicular to the horizontal portion 
of the bone varies with different ages. In early infancy it is very 
obtuse ; indeed, the two portions are nearly on the same plane. In 
adult life a right-angled relation is obtained, and this changes again 
to the obtuse as age advances, and the teeth fall out. Taking 
advantage of a knowledge of these changes, the surgeon is enabled 
to correct, in young life, the great deformity of an unduly projecting 
lower jaw. 

Looking at the external face of the body, the attention is first at- 
tracted by a prominent foramen situated beneath the bicuspid teeth. 
This foramen is called the mental, and from it pass out, to be dis- 
tributed to the lip and gum, the inferior dental artery and inferior 
dental nerve ; the situation of the foramen represents the line of re- 
lation between the hard and spongy portions. It is at this opening 
that section of the nerve is occasionally made for severe and resisting 
labial neuralgia. A bristle passed into this foramen, inclined back- 
ward, is directed along a canal at the base of the teeth, and emerges 
at an opening situated on the inner face of the ramus. Passed for- 
ward, it enters a smaller canal, which continues under the central 
teeth, carrying to these organs branches of the'nerve and artery. 
An oblique line — the external oblique line, as it is called — fairly 
divides the surface of the body into two triangles. This line is for 
the attachment of muscles, and accommodates the buccinator, in 
part, the depressor anguli oris, and the depressor labii inferioris In 
old persons, after the loss of the teeth, and absorption of the alveolar 
process, it is found to run almost along the upper surface. The 
centre vertical line, called the symphysis, represents the position or 
division existing in the young bone, union of the two halves not 
occurring until about the end of the first year. The levator menti 
muscle has its origin from the fossa at the side of this line. The 
mental process, the tubercle at the base of the symphysis, is only 
a thickening, for the greater strength of the part. Yiewed from 
above downward, the body of the lower jaw is concave; from behind 
forward it is convex. 

The external face of the ramus or perpendicular portion of the 
bone exhibits a quadrilateral aspect, broken above by a notch, the 
sigmoid, which separates the two projecting processes. The anterior 
of these processes is a thin, flattened, triangular eminence, giving 
attachment to the masseter and temporal muscles. The posterior 



40 ORAL DISEASES AND SURGERY. 

eminence, the condyloid process, is an oval projection, convex and 
smooth, with its face covered with articular cartilage, and having 
its greatest width from side to side. This process articulates the 
bone with the temporal, and is occasionally the seat of fracture and 
luxation. 

The internal face of the bone presents the same general view as 
the external. 

A ridge, the mylo-hyoid, divides the body by its oblique line into 
two parts. To this ridge is attached, or rather from it has origin, a 
muscle of the same name. This muscle, with its fellow of the oppo- 
site side, forms the floor of the mouth, so that looking at the line one 
sees exactly how much of the bone is within and how much without 
the oral cavity. Just below the line, about midway of the body of 
the bone, is seen a fossa or depression, the submaxillary, for the 
accommodation of the gland of that name. The mesial line or sym- 
physis presents on either side two tubercles, called the genial 
tubercles, to which are attached the genio-hyoglossi and the genio- 
hyoideus muscles. Outside of these tubercles, on either side, are 
two fossae for the lodgment of the sublingual glands ; these fossae 
are called by the name of the glands. It will be observed that as 
these fossae lie above the ridge, the lingual glands must be within 
the mouth, while the submaxillary fossae being below it, these glands 
are without the cavity. One most important feature to remark is 
the relation of the anterior border of the vertical portion of the bone 
to the molar teeth. It not unfrequently happens that this border so 
nearly approximates the second molar that there is no room for the 
eruption of the third ; the most formidable inflammations sometimes 
result from such a cause, the crown of the tooth being held down 
under the ramus. Extraction of the adjoining anterior tooth, it will 
be seen, would allow the confined one to fall forward. 

A marked feature of difference between the internal and external 
face of the ramus is the existence in the former of a large foramen, 
the inferior dental, for transmission into the canal alluded to, as 
passing beneath the teeth, of the inferior maxillary vessels and 
nerve. The position of this foramen is to be appreciated by accu- 
rate measurement, as just within it is performed the operation of 
section of the nerve. A groove, the mylo-hyoid, transmits to the 
muscle of the ridge an artery, which comes from the inferior maxil- 
lary just as it is about to enter its canal. Attached to the border 
and internal face of the coronoid process is the tendinous expansion 
of the temporal muscle, while to the face of the condyloid is attached 



ANATOMY OF THE MOUTH AND FACE. 



41 



the pterygoideus externus, the internal pterygoid being related to 
the angle. The semilunar depression, separating the two condyles, 
the sigmoid notch, is crossed by the masseteric artery and nerve, 
while in its immediate proximity are the internal carotid and internal 
maxillary arteries. 

Figs. 5 and 6. — Palate Bone. 





Posterior view of the right palate bone. 
1, palate plate; 2, nasal plate; 3, pyramidal 
process ; 4, articular border for the left palate 
bone ; 5, palate spine ; 6, ridge for junction 
with the turbinated bone; 7, spheno-palatine 
notch, between 8, the orbital, and 9, the 
sphenoidal process ; 10, groove for the in- 
ternal pterygoid process of the sphenoid 
bone ; 11, position of the posterior palatine 
foramen. 



Exterior view of the right palate bone. 
1, rough surface articulating with the su- 
perior maxillary bone, and diminishing the 
aperture of the maxillary sinus ; 2, posterior 
palatine canal, completed by the tuberosity 
of the superior maxillary bone ; 3, spheno- 
palatine notch ; 4, 5, 6, orbital process ; 4, 
surface directed toward the pterygo-max- 
illary fossa; 5, orbital surface; 6, maxillary 
border ; 7, sphenoidal process ; 8, pyramidal 
process. 



The palate bone in position is seen to form the back part of the 
hard palate, a portion of the floor and side of the nares, and a part 
of the orbital cavity. It also enters into the formation of three 
fossae: the zygomatic, spheno-maxillary, and pterygoid. Like the 
inferior maxillary, the bone consists of two portions : one horizontal, 
the other at right angles with it, or vertical. The horizontal portion 
is irregularly quadrilateral, presenting two surfaces and four borders : 
the upper of the two surfaces is concave, and forms the back part of 
the floor of the nares; the lower or under surface is also concave, and 
forms the back of the hard palate. The suture of connection with 
the maxillary bone is always plainly seen, and is called the palato- 
maxillary suture. 

In glancing at the bone from its posterior view, it is seen very 
markedly to resemble the letter L. Stud}nng it in detail, we may re- 
mark, first, the spine, situated at the base of the interpalatal suture, 
and which gives attachment to one of the motores uvulae muscles; 
passing toward the vertical portion, the concave character of both 



42 ORAL DISEASES AND SURGERY. 

nasal and palatine faces is observed, the former much more marked 
than the latter. This nasal concavity is seen to end at a crest or 
ridge on the vertical portion. This ridge is the most posterior articular 
surface of the inferior turbinated bone, and the space below it is a part 
of the inferior meatus. The base of the vertical portion is pyramidal, 
and ends in a process called the pterygoid or tuberosity, its articu- 
lation being with the pterygoid plates of the sphenoid. At the 
back part of this process are seen three grooves : the middle one, 
wide and smooth, forms part of the pterygoid fossa, and gives 
attachment to the internal pterygoid muscle ; the two lateral are 
rough and uneven, and articulate with the anterior border of each 
pterygoid plate. 

Passing upward, the prominent feature is the sphenoid process. 
This is a comparatively thin plate, made up of an articular and non- 
articular surface, a groove and a notch. The articular surface as- 
sociates the plate with the sphenoid bone ; the non-articular enters into 
the composition of the zygomatic fossa. The groove contributes to 
the formation of the pterygopalatine canal ; and the notch, closed 
in above by the orbital process, forms the greater part of the 
spheno-palatine foramen. This process also contributes, by one of 
its surfaces, to the lateral wall of the nasal fossa. 

The orbital process, resting on the sphenoidal, is composed of five 
plates, or surfaces, and includes a cavity. Of these processes, three 
are articular, two, free surfaces. .The articular are the maxillary, 
the sphenoidal, and the ethmoidal, associating the process with these 
bones. The free surfaces are the orbital, forming a small part of the 
orbital cavity, and the zygomatic, entering into the composition of 
the zygomatic fossa. 

Looking on the inner face of the bone, we remark, first, the articu- 
lar process. This process or surface associates the bone with its 
fellow of the opposite side ; above, it forms, with its neighboring 
piece, a ridge receiving the vomer. The body of this face seems 
made up of two great concavities, with a separating ridge. This 
ridge articulates the inferior turbinated bone ; the concavity above 
is part of the middle meatus ; that below, part of the inferior 
meatus ; the ridge or crest is called the inferior turbinated crest. 
A second crest, situated at the upper boundary of the middle meatus, 
articulates the lower scroll of the ethmoid, or the middle turbinated 
bone. This is called the superior turbinated crest. Just below it is 
seen the now perfected notch in the sphenoidal process, the spheno- 
palatine foramen, for the transmission of the vessels and nerve of 



ANATOMY OF THE MOUTH AND FACE. 43 

that name. Above the superior crest is seen the posterior part 
of the superior meatus, a horizontal groove, bounded above by the 
lower border of the ethmoidal face of the orbital process. 

The orbital process, seen from this side, presents three surfaces : 
the maxillary in front, the orbital above, and the ethmoidal in- 
ternally. 

The lateral surfaces of the bone are almost entirely articular. 
That looking front associates in its full length with the superior 
maxillary bone ; that looking back, with the sphenoid, through its 
pterygoid processes. This very full articulation with these two 
bones leads us to speak of the palate bone as being wedged between 
them, and being supported by them. 

The articulations of the palate bone are with seven others : the 
superior maxillary, the inferior and superior turbinated, the vomer, 
the sphenoid, the ethmoid, and its fellow of the opposite side. 

The muscles attached to it are the tensor palati, the motor uvulae, 
and the internal and external pterygoid. 

THE VOMER. 

The vomer, plowshare-shaped, constitutes a portion of the septum 
narium. It articulates below with the interpalatine suture of the 
superior maxillae and palate bones ; above, with the perpendicular 
plate of the ethmoid ; by its base with the laminae and rostrum of 

Fig. 7. — The Tomer. 




View of left side. 1,1, broad groove receiving the rostrum of the sphenoid bone; 
2, 2, inferior border articulating with the palate plates of the superior maxillary and 
palate bones ; 3, posterior border, the dividing line of the posterior nares ; 4, 4, groove 
border receiving a narrow slip of cartilage, situated between the vomer and the nasal 
plate of the ethmoid bone ; 5, 5, border for the cartilaginous septum of the nose ; 6, 6, 
nasal surface. 

the sphenoid bone ; in front it associates with the triangular cartilage ; 
posteriorly it is seen separating the nares. The naso-palatine groove, 
seen running from the base, forward and downward, toward the 
triangular cartilage, transmits the naso-palatine nerve to the inter- 
palatine canal. 



44 ORAL DISEASES AND SURGERY. 

Occasionally it is the case that the vomer is found markedly bent 
to one side or the other, and this to such an extent, frequently, as 
completely to obliterate one of the nares, requiring an operation for 
its relief. The vomer is also subject to syphilitic attacks, and fre- 
quently breaks down, allowing the arch of the nose to fall in. 

Fig. 8. — Articular Kelations of Vomer. 

m 




Vertical section of the face, exhibiting the osseous nasal septum. 1, frontal bone ; 
2, frontal sinus; 3, nasal spine of the frontal bone; 4, nasal bone; 5, nasal spine of the 
superior maxillary bone ; 6, nasal pi-ocess of the same bone ; 7, border of the palate plate 
of the same; 8, incisive foramen; 9, left posterior naris ; 10, palate plate of the palate 
bone ; 11, nasal plate of the etbmoid bone ; 12, ethmoidal crest ; 13, vomer ; 14, left turbi- 
nated bone ; 15, sphenoidal sinus ; 16, internal pterygoid process ; 17, external pterygoid 
process. 

The articulation is seen to be with six bones ; the two superior 
maxillary, the two palate, the sphenoid, and the ethmoid ; also with 
the cartilaginous septum, not shown in the view, but occupying the 
triangular break. 

Running across each lateral face of the nasal cavities are three 
scrolls, known as the turbinated bones. Of these scrolls, the two 
upper are simply processes, or portions of the ethmoid bone ; the 
lower is a distinct piece, and is called the inferior turbinated bone. 

Observing the position of these scrolls, it is remarked that each 
curves over a portion of the sides of the nares. The spaces thus 
inclosed are called the meatus. The low x er or inferior of these 
cavities is bounded below by the floor of the nares ; above by the 
inferior turbinated bone. An opening seen about its middle is the 



ANA TO M Y OF THE MOUTH AND FACE. 



45 



outlet of the lachrymal canal. The middle meatus is the space 
bounded below by the upper surface of the inferior scroll ; above by 
the lower surface of the middle scroll. A foramen seen in this meatus 

Fig. 9. — Position and Relations of Turbinated Bones. 




View of the outer wall of the right nasal fossa. 1, frontal bone ; 2, its orbital plate ; 
3, its nasal spine; 4, nasal bone ; 5, ethmoid bone; 6, its upper turbinated process; 7, its 
lower turbinated process; 8, turbinated bone; 9, process of the lachrymal bone within 
the position of which is the lachrymo-nasal duct; 10, nasal spine of the superior maxil- 
lary bone; 11, naso-palatine canal ; 12, palate plate of the superior maxillary bone; 13, 
nasal process of the latter ; 14, external pterygoid process ; 15, internal pterygoid pro- 
cess ; 16, nasal plate of the palate bone; 17, its palate plate; 18, posterior palatine fora- 
men ; 19, superior meatus of the nose ; 20, middle meatus ; 21, inferior meatus ; 22, frontal 
sinus ; 23, sphenoidal sinus ; 24, its communication with the upper back part of the nose; 
25, spheno-palatine foramen; 26, orifice of the maxillary sinus. 



is the outlet of the antrum. The superior meatus is the slit seen 
between the two upper scrolls. 

The distinct, or inferior turbinated bone, is a thin, spongy scroll, 
having a base of attachment the whole length of the lower crest 
seen on the nasal surfaces of the maxillary and palate bones ; the 
opposite, or inferior edge, is free, and lies in the middle of the in- 
ferior meatus. Viewed from its inner surface, the bone presents a 
most irregular appearance, being perforated with numerous aper- 
tures, sulci, and grooves, for the accommodation of arteries and veins. 
Two processes, the lachrymal and the ethmoid, are seen to break the 

regularity of the upper convexity. The anterior — the lachrymal 

articulates with the inferior angle of the lachrymal bone, and with 
the nasal crest of the maxillary bone, thus assisting in forming the 



46 



ORAL DISEASES AND SURGERY. 



lachrymal canal. The posterior — the ethmoidal — articulates with the 
descending unciform process of the ethmoid bone. Turning here the 
bone, we see a third process, or division, as it were, made in the 
ethmoidal. This process is called the maxillary. It curves down- 
ward within the inferior meatus, assisting in filling up the antral 
orifice, and, in its attachment, steadies the bone firmly on the side 
of the nares. Externally, the general appearance of the bone is con- 
cave; internally, or looking toward the septum narium, it is convex. 
If the external surface were convex, and the processes absent, the bone 
might very well be likened in shape to the Indian stone arrow-head. 

The turbinated bone is very subject to specific inflammation, and 
which, without great care, is apt to end in its death. 

The bone articulates with four others : the ethmoid, the lachry- 
mal, the maxillary, and the palate. No muscles are attached to it. 

THE ETHMOID BONE. 



A horizontal cribriform plate of bone, with a crest along its middle; 
a perpendicular plate dropping down from the centre of this first 

piece ; two little oblong square 



Fig. 10. 



-Ethmoid Bone — Genekal 
View. 



boxes, hung on either side of the 
perpendicular plate, leaving the 
space of a narrow slit between 
the boxes on either side and the 
plate, and we have the complete 
idea of the ethmoid bone. Look- 
ing at the bone from above, we re- 
mark, first, the crest — crista galli 
it is called — giving attachment to 
the falx cerebri. On either side 
of this crest is seen a depression 
perforated with a number of fora- 
mina. These depressions lodge 
the olfactory bulbs, and the fora- 
mina transmit to the nose the 
olfactory filaments, the three sets 
having corresponding foramina. 
A slit seen at the side of the 
crista galli transmits the nasal 
branch of the ophthalmic nerve. 
Looked at anteriorly, the crest is seen to terminate in two little 




1, orbital surface of the lateral mass ; 2 
posterior extremity of the cribriform plate, 
which unites the lateral masses, and is de- 
pressed and perforated with numerous fora- 
mina on each side of the ethmoidal crest 3; 
the two oblique processes in advance of the 
latter are the ethmoidal wings ; 4, anterior 
extremity of the nasal plate; 5, the ethmoidal 
sinuses. 



ANATOMY OF THE MOUTH AND FACE. 47 

horns or wings; these articulate with depressions in the os frontis, 
and occasionally in a manner so imperfect as to leave an opening 
or foramen. When existing, this foramen accommodates a nasal 
vein, which passes upward, to terminate in the longitudinal sinus 5 
the rupture of this vein, discharging the sinus, has saved many 
lives in attacks of congestion. 

The perpendicular plate, exhibited by the removal of one of the 
lateral masses, is simply a thin plate of bone. This, descending in 
the middle line of the nose, assists the vomer in separating this 
cavity into two lateral halves. In front, it is received into the 
groove between the two nasal bones; below, it looks downward and 
forward, and receives the triangular cartilage ; back of this it articu- 
lates with the vomer, and still farther back with the sphenoid. 

On each side of the plate are seen numerous grooves leading from 
the foramina in the horizontal or cribriform plate ; these are chan- 
nels receiving and shielding the inner olfactory filaments. 

The boxes or lateral masses are very loose, and areolar-like, and 
constitute a series of cells. Disarticulated, many of these cells 
appear broken ; but when associated with the ethmoidal fissure of the 
frontal bone, with the sphenoidal scrolls, with the orbital processes 
of the palate bones, and the nasal processes of the maxillary and 
palate bones, the cells are found to be completed. The union of 
these cells, more or less directly, with the common nares, and the 
fact that they are all lined by a mucous membrane continued from 
these fossae, explain the sense of congestion and fullness known as 
" cold in the head." 

The outer surface, or face of the boxes, looks very much in color 
like the common clarified quill, is semi-translucent, square in shape, 
and very smooth. Referring to the view of the skull (Fig. 1), this 
surface will be seen entering into the composition of the orbital 
cavity. 

The portion of the ethmoid which receives and articulates the 
process passing upward from the inferior turbinated bone is a 
hook-like projection from the under surface of these lateral masses. 
It is called the unciform process, and assists in narrowing the orifice 
of the antrum and supporting the masses. 

The internal surface of each lateral mass approaches the perpen- 
dicular plate. At the upper part is the narrow fissure, bounded by 
a scroll-like process on the surface, known as the superior meatus. 
The scroll has received the name of the superior turbinated bone. 
Below this first scroll, on the same surface, is a second. This second 



48 ORAL DISEASES AND SURGERY. 

scroll is called the middle turbinated bone, and the space below it, 
between it and the inferior turbinated bone, is the middle meatus. 

In looking at the ethmoid bone in position, it will be seen to be 
wedged in between the nasal, frontal, lachrymal, and maxillary 
bones in front, and the sphenoid behind ; below, it is supported by 
the turbinated, vomer, and palate bones. Blows received upon the 
bridge of the nose have not unfrequently carried the crista galli into 
the substance of the brain ; while maxillary diseases find an easy 
road to the base of the cranium through the nasal communication 
with the ethmoidal cells. 



THE SPHENOID BONE. 

The sphenoid bone, named from its wedge-like relations to other 
bones of the cranium, has been frequently and most aptly compared 
in appearance to a " bat" with extended wings and unflexed legs. 

Pig. 11. — The Sphenoid Bone — Upper Yiew. 




1, pituitary fossa; 2, olivary pi-ocess ; 3, declivity; 4, anterior clinoid process; 5, pos- 
terior clinoid process ; 6, posterior border of the body; 7, cerebral surface of the great 
wing; 8, articular surface for the frontal bone: 9, articular border for the temporal bone; 
10, spinous process; 11, small wing; 12, border articulating with the orbital plate of the 
frontal bone; 13, border joining the ethmoid bone; 14, optic foramen; 15, sphenoidal for- 
amen; 16, rotund foramen; 17, oval foramen; 18, spinous foramen; 19, groove for the 
internal carotid artery. 

In looking at the disarticulated bone, we first observe a central 
portion or body ; this body is irregularly square, and marked on all 
its surfaces with features which one at once infers to be possessed 
of anatomical significance. Extending laterally on either side from 
the body are two great wings ; these wings are made double by a 
lacerated foramen, and instead of being spoken of and described as 
a single pair, are mostly viewed as two pairs, — the larger portion 
being called the greater wings, the smaller pair the lesser wings. 



A NATO M Y OF THE MOUTH AND FACE. 49 

The legs, falling from the base of the cranium, are found separated 
by a notch into two portions, — this separation, however, being much 
more marked behind than in front: they have received the name of 
pterygoid processes. 

Tig 12.— Tfte Sphenoid Bone— Front View. 

(few 




1, 2, sphenoidal crest and rostrum for joining the nasal plate of the ethmoid bone and 
the vomer; 3, entrance of the sphenoidal sinuses; 4, small wing; 5, optic foramen 
piercing its base ; 6, sphenoidal foramen ; 7, rotund foramen ; 8, orbital surface of the 
great wing; 9, temporal surface of the same; 10, ridge separating the temporal and 
spheno-maxillary fossa? ; 11, position of the pterygopalatine canal ; 12, pterygoid canal ; 
13, internal pterygoid process, ending in a hook; 14, 15, external pterygoid process ; 16, 
spinous process; 17, oval foramen; 18, spinous foramen. 

Beginning a study of the body from its superior or cranial sur- 
face, attention is first naturally directed to a saddle- like depression 
occupying a large portion of this face. This depression lodges a 
little body attached to the floor of the third ventricle, the pituitary 
body ; hence it is called by many authors the pituitary depression 
or fossa; and from its resemblance to the Turkish saddle it is 
as frequently named the sella turcica. A number of little pits 
seen on the floor are foramina transmitting vessels of nutrition. 
On either side are two processes ; these correspond to two others, 
terminating the plate of bone which represents the back of the 
saddle. The four have been compared to the posts of a bedstead, 
and are called clinoid processes. Passing forward, an olive-shaped 
eminence is next noticed, — the olivary process; and directly in front 
of this, a groove or oblong fossa. This groove has resting in it the 
commissure of the optic nerve, and hence is called the optic groove. 
Passing directly forward, we find the surface terminate in a spine or 
projecting point; this point articulates the surface with the eth- 
moidal bone, and is called the ethmoidal spine ; between this spine 
and the optic groove is a slight eminence falling off on either side 
into aline of depression; these lines lodge the olfactory nerves. 
Two foramina, seen on this surface at either terminus of the optic 

4 



50 ORAL DISEASES AND SURGERY. 

groove, are called optic foramina; they transmit to the orbital cavi- 
ties the optic nerves and ophthalmic arteries. From the back of the 
saddle the surface is seen to slope gradually downward ; this con- 
cave plane lodges the medulla oblongata, and terminates at the line 
of union with the occipital bone. On either side is situated a tor- 
tuous depression, in which lie the internal carotid artery and the 
cavernous sinus. 

Turning now to the anterior surface, we observe, first, a rostrum 
or beak, for articulation with the perpendicular plate of the ethmoid. 
On either side of this beak are seen scrolls of bone, or rather lamellae, 
— the sphenoidal turbinated bones, as they are called. These la- 
mellae, we find, imperfectly close sinuses which hollow out the sub- 
stance of the body, and which, in articulation, are found to commu- 
nicate with the upper part of the nose, and frequently with the 
ethmoidal cells ; being lined with the mucous membrane of the 
nares, and subjected consequently to the sympathies of continuity. 

The inferior surface presents us, first, with the rostrum or beak; 
continued from the anterior face, this spine is received into a groove 
or fissure in the vomer. On either side are laminae of bone, which 
pass to the pterygoid processes ; these plates or laminae are called 
vaginal processes. Close to the pterygoid process is seen a groove, 
which the sphenoidal process of the palate-bone converts into a 
canal ; this groove transmits the pterygo-palatine vessels and pha- 
langeal nerve. 

The posterior surface in this bone exhibits simply a quadrilateral 
sawed surface, a union existing with the occipital at this point, 
which has required the saw for its separation. Hence it has been 
a common practice with many writers to consider the sphenoid and 
occipital as one bone, and to refer to them as the spheno-occipital bone. 

The Wings, which may next claim attention, are called the greater 
and lesser, the separation existing at the lacerated foramen. The 
greater wings extend laterally, and assist largely in forming the 
floor of the fossae which receive the middle lobes of the brain. 
Looked at from the encranial aspect, attention is first attracted to 
six foramina, — three on either side. The first of these is a round 
hole, and is called the foramen rotundum ; it transmits from the 
brain to the superior maxillary bone the second branch of the fifth 
nerve. The second hole is oval in shape ; hence called the foramen 
ovale : it transmits the third, or inferior maxillary branch of the 
fifth. The third, the foramen spinosum, transmits the middle me- 
ningeal artery. A fourth foramen is occasionally found in the great 



ANATOMY OF THE MOUTH AND FACE. 51 

wing, — the vesalii. When existing, it is occupied by a small vein. 
The general floor of these wings is concave, and marked with eleva- 
tions and depressions for the accommodation of neighboring convo- 
lutions. 

Turning the bone, these wings are seen to be made up of three 
surfaces : the encranial face, as just described ; an external surface, 
occupying, when in articulation, a place in the base of the skull ; and 
an orbital surface. 

The external surface is irregularly convex, and is separated into two 
portions by a ridge called the pterygoid. The superior of these two 
faces is seen entering into the composition of the temporal fossa for 
lodgment of the temporal muscle. The inferior face lies beneath the 
zygoma, and forms part of the fossa of this name, giving attachment 
to the external pterygoid muscle. Running from the postero-lateral 
angle of the surface is seen a prolonged spine : to this are attached 
the laxator tympani muscle and the internal lateral ligament of the 
lower jaw. 

The orbital face of the wing assists in forming the outer boundary 
of the orbit ; it is quadrilateral in form, smooth, and concave. Below, 
it has a somewhat rounded border, and enters into the formation of 
the spheno-maxillary fissure; internally, it assists in forming the 
sphenoidal fissure. At the lower edge of the inner border is a deli- 
cate spine, giving origin to one head of the external rectus muscle. 
The foramina generally seen on this face are called orbitar foramina : 
they transmit small arteries. 

The lesser wings, frequently described as the processes of In- 
grassias, are seen on the encranial surface extending outward, over- 
lying at their apices the great wings. These wings are triangular 
in shape, having their bases associated with the body of the bone. 
In articulation they complete the posterior boundary of the anterior 
fossae of the cranium, and are lodged in the fissure of Sylvius. The 
fissure or slit which separates them from the great wings is called 
the lacerated foramen. It transmits the first or ophthalmic branch 
of the fifth nerve, the third, fourth, and sixth nerves, and the oph- 
thalmic vein. The lesser wings are connected with the body by two 
footstalks, inclosing within them and assisting in forming the optic 
foramina. A process seen jutting backward from the foramen is 
called the anterior clinoid process ; to it is attached the common 
tendon of the recti muscles. 

The legs or pterygoid processes, seen falling from the point of 
union of the great wings with the body, consist of two plates, sep. 



52 



ORAL DISEASES AND SURGERY. 



arated behind by a deep notch, but united almost fully in front. The 
external plate is broad and curved, and forms part of the zygomatic 
fossa ; to it is attached the external pterygoid muscle. The internal 
face forms part of the pterygoid fossa, and gives origin to the inter- 
nal pterygoid. The internal plate has a particular interest ; it ends 
in a tubercle or hook-like process, which is felt in the mouth just 
back of the maxillary tuberosity, — the hamular process; around it 
turns the tendon of the tensor palati muscle, — a tendon to be divided 
in the operation for cleft palate. The base of this internal plate forms 
a fossa, the scaphoid, from which originates the tensor muscle just 
alluded to. The outer surface of this plate forms the pterygoid 
fossa ; the inner assists in forming the outer posterior boundary of 
the nares. 

The base of the pterygoid process is quite broad, and in front gives 
support to Meckel's ganglion. The vidian canal passes through it. 

The sphenoid articulates with all the bones of the cranium, with 
the two malar, the vomer, and two palate bones of the face. 

The muscles to which it gives origin are the temporal, external, 
and internal pterygoid, tensor palati, laxator tympani, levator pal- 
pebraB, the recti of the eye, and superior oblique of eye. 

THE NASAL BONE. 



Boxe. 



The figure exhibits the faces of a left nasal bone articulating 
with its fellow, which is its counterpart; the two occupy the quadri- 
F _ N ^ lateral space existing between the tw T o maxillary 

bones and the frontal, and form the prominence 
known as the nasal bridge. That these bones vary 
considerably in shape would be inferred from va- 
riations in the shape of the bridge so frequently 
seen. Looked at from above downward, each 
bone is observed to be concave, while viewed 
from side to side, it is convex; several light 
grooves are commonly noticed on the surface 
for the accommodation of vessels ; the foramen 
seen about the centre transmits a small vein. 

The inner surface reverses relations with the 

outer — being convex from above below, concave 

from side to side. Its only feature of interest is 

a groove for the lodgment of the nasal nerve. 

The borders of the bone are three articular and one free. The 




Anterior view of 
the left nasal boxe. 
1, frontal border ; 2, 
nasal border ; ?>, maxil- 
lary border ; 4, lower 
border ; 5, nasal fora- 
men. 



A NAT 031 Y OF THE MOUTH AND FACE. 



53 



superior, serrated and somewhat narrow, fits in the frontal notch, 
forming the fronto-nasal articulation. The lateral border is bev- 
eled, at the expense, above, of the internal plate, below, of the 
external, and fits with corresponding bevelings of the nasal pro- 
cesses of the maxillary bone. Internally, or mesially, the bone 
articulates with its fellow of the opposite side, being prolonged 
below into a crest, which forms a part of the nasal septum, and 
articulates with the nasal spine of the frontal above, and the 
ethmoidal perpendicular plate below. The lower border is free, at 
least so far as any bony articulation is concerned, giving attachment 
by a thin, sharp edge to the lateral cartilage of the nose. A notch, 
seen at the centre of this border, transmits the nerve occupying the 
groove on the inner surface. 



Fig. 14. 



-The Malar Bone. 

3 



THE MALAR BONE. 

The malar, or cheek bones, may be likened to two bony pads laid 
on either lateral aspect of the face for the purpose of influencing a 
general convexity. Each bone is ir- 
regularly quadrilateral, supported 
above by articulation with the frontal, 
sphenoid, and superior maxillary 
bones ; in front by the malar process 
of the maxillary ; posteriorly by the 
zygomatic process of the temporal. 

The bone presents two surfaces, 
four processes, and four borders. The 
external surface, convex and smooth, 
presents little of interest ; the fora- 
men, seen upon this face, is some- 
times replaced by two or more ; they 
are simply the orifices of canals, trans- 
mitting unimportant vessels. The 
surface, in relationship, is mostly 
covered by the orbicularis palpebrarum muscle, while the zygomatici 
have origin from the lower and inner aspect. 

The interna] face is concave, and assists in forming, above, the 
temporal fossa, below, the zygomatic. It yields partial origin to both 
the temporal and masseter muscles. 

Of the four processes, the orbital is the most interesting; turning 
at right angles with the external face of the body, it assists in form- 




OUTER VIEW OF THE RIGHT MALAR BONE. 1, 

external or facial surface ; 2, malar fora- 
men ; 3, frontal process; 4, 5, orbital bor 
der; 6, maxillary border; 7, zygomatic 
process; 8, temporal border; 9, inferior 
border. 



54 



ORAL DISEASES AND SURGERY. 



ing a portion of the outer wall of the orbit and orbital ridge. The 
frontal is thick and serrated, and articulates with the external angu- 
lar process of the frontal bone. The maxillary is rough, and trian- 
gular in shape, and attaches the bone in front. The zygomatic is 
sharp and flat, and forms part of the yoke overlying the ridge sep- 
arating the zygomatic from the temporal fossa. 

The four borders are the orbital, the maxillary, zygomatic, and 
temporal. These borders correspond with the relations named, but 
have no interest apart from the processes. 

THE LACHRYMAL BONE. 



Fig. 15.— The Lach 
kymal Bone. 




Looking at the view, or, much better, at the articulated skull, the 
lachrymal bone is seen to occupy a position of some prominence in 
the composition of the orbit. A ridge on its 
anterior surface divides the bone into two parts : 
one part, called its orbital face (bounded above 
by the orbital face of the horizontal plate of the 
frontal bone ; laterally, by the os planum of 
the ethmoid ; below, by the orbital surface of 
the maxillary bone), enters into the compo- 
sition of the orbital cavity. The face, to the 
inner side of the ridge, is smooth and concave, 
and articulates with the nasal process of the 
maxillary bone, internally, and with the lach- 
rymal process of the turbinated, below; these 
three bones in their union form the ductus ad 
nasum, or lachrymal canal, transmitting the 
tears to the inferior meatus. 

The bone, by its internal or nasal surface, 

enters into the composition of the middle 

meatus, and assists in closing in the anterior 

ethmoidal cells. Like the external surface, it is divided into two 

faces, the line of division being a depression corresponding with the 

ridge on the opposite surface. 

Only one muscle has its attachment to this bone, — the tensor tarsi. 



External tiew of the 
right lachrymal bone. 1, 
orbital surface; 2, lachry- 
mal fossa; 3, small process 
bounding the latter infe- 
riority ; 4, frontal border ; 
5, ethmoidal border ; 6, max- 
illary border; 7, process 
articulating with the tur- 
binated bone. 



THE HYOID BOXE. 



The os hyoides is the bone situated on the anterior part of the 
neck between the chin and sternum. In shape it somewhat resem- 



ANATOMY OF THE MOUTH AND FACE. 



55 



Fig. 16. — The Hyoid Bone. 




1, body ; 2, greater horn ; 3, lesser 
horn. 



bles the ordinary horseshoe, and is held in place entirely by a series 
of antagonizing muscles, of which it gives attachment to some ten 
pairs. A glance at the bone naturally divides it into a body and 
four processes or horns ; the greater of these cornua extend quite 
widely over the lateral aspect of the neck, 
giving attachment to the hyo-glossus, 
middle constrictor of the pharynx, and 
thyro-hyoid muscles, and by a bulb, con- 
stituting its extremity, to the thyro-hyoid 
ligament ; it also serves as our best guide 
to the position of the lingualis artery. 
The lesser cornua are simply two conical 
eminences, more or less prominent on 

different specimens'; starting out at the point of junction of the 
great horns with the body, they look upward toward the chin, and 
serve to afford attachment to the stylo-hyoid ligaments. 

The body is irregularly quadrilateral in shape, convex in front, 
concave behind. A crucial ridge, the intermuscular, divides the 
front face into four fossas. This surface is exclusively devoted to 
the attachment of muscles ; above, to the genio-hyoid and the genio- 
hyo-glossus ; below, to the stylo-hyoid, mylo-hyoid, and digastricus. 
The posterior surface is smooth and concave, and occupies a position 
just in front of the epiglottis, being separated from it above by some 
cellular tissue and a membrane called, from its relationship, the 
thyro-hyoid. 

Fig, 17. 




Anteroposterior section of the cranium, exhibiting the mode by which the con- 
nection of the different bones contributes to preserve its integrity. 1, parietal bone; 
2, frontal bone; 3, its orbital plate; 4, frontal sinus; 5, body of sphenoid bone; 6, 
sphenoidal sinus ; 7, occipital bone ; 8, marginal ridge of the occipital foramen. 



Gti 



ORAL DISEASES AND SURGERY. 



Fig. 18. 




YlEW Or THE RIGHT HALF OF THE BASE OF THE SKULL. 1, palate 

plate of the superior maxillary boiie ; 2, palate plate of the 
palate bone; 3, vomer; 4, internal pterygoid process; 5, ex- 
ternal pterygoid process ; 6, pyramidal process of the palate 
bone ; 7, under surface of the great wing of the sphenoid bone ; 
8, its temporal surface ; 9, zygomatic arch ; 10, zygomatic pro- 
cess of the malar bone : 11, zygomatic process of the temporal 
bone ; 12, squamous portion of the temporal bone ; 13, glenoid 
tubercle ; 14, glenoid cavity ; 15, vaginal process, its outer 
border constituting the auditory process ; 16, styloid process ; 
17, external auditory meatus ; 18, mastoid process ; 19, digas- 
tric groove; 20, basilar process of the occipital bone co-ossified 
with the body of the sphenoid bone; 21, condyle; 22, occipital 
protuberance ; 23, superior, and 24, inferior semicircular ridges ; 
25, occipital foramen ; 26, incisive foramen ; 27, posterior pala- 
tine foramen : 2S, spheno-maxillary foramen ; 29, posterior 
naris; 30, oval foramen; 31, spinous foramen; 32, lacerated 
foramen ; 33, Eustachian tube ; 34, carotid canal ; 35, jugular 
foramen ; 36, stylo-mastoid foramen ; 37, 38, foramina for 
veins. 



CHAPTER II. 



THE MOUTH, 



Studying the mouth from the living subject, we remark, first, an 
entrance of two fleshy folds, the lips ; separating these, we are met 
by a second portal, the teeth ; the space existing between these two 
entrances is called the hall or vestibule ; opening this inner gate- 
way, by depressing the lower jaw, we are introduced into the oral 
cavity proper. 

The mouth is the commencement of the alimentary canal. It has 
as offices, expression in sound, the reception of food, gustation, 
mastication, and insalivation ; consequently must possess organs 
and agencies pertinent to these ends. 

Looking into the mouth, we observe that it is an oval cavity, 
bounded posteriorly by a veil or curtain. This falls obliquely 
toward the fauces, having a central pendulum, terminating laterally 
in arched curves. We can see beneath this veil, or between it and 
the base, and thereby recognize the cavity we are viewing to be 
simply the commencement of a canal. Every part of the cavity we 
remark to be covered by a common membrane, which membrane we 
find to associate externally on the lips with the skin ; internally we 
see it passing back of the veil down the throat, — this is a mucous 
membrane, and examination reveals it to be continuous from this 
cavity to the outlet of the rectum. The teeth, thirty-two in number 
in the adult, are placed in two harmonizing or articulating arches or 
curves, and are, in shape or character, correspondent with omniv- 
orous habits. Thus certain of their number, the incisors, as they 
are called, are so arranged as to cut or incise. Certain others, the 
cuspidati or canines, are spear-shaped, and tear or lacerate. Still 
others, the bicuspidati and molars, have broad and roughened sur- 
faces, acting the part of grinders. The tongue, a muscular body, 
rests within the lower dental arch ; it evidently is fitted and suited 
to preside over the labor of the teeth, receives or rejects articles to 
be comminuted, places and retains such articles in position to be 

(57) 



58 ORAL DISEASES AND SURGERY. 

masticated, and, when ready to be swallowed, rolls up masses into 
a bolus, and passes them into the pharynx. 

The roof of the cavity, beginning with the palatine faces of the 
teeth, is made up evidently of hard and soft tissues. The hard por- 
tion we discover to be the flesh-covered alveolar and palatine pro- 
cesses of the superior maxillary bones and the palate processes of 
the palate bones. The soft portion dissection reveals to be a simple 
attached basement tissue covered with the common membrane. 

The uvula, the central pendulous termination of the soft palate, 
consists of two symmetrical muscles inclosed in the common mucous 
membrane. The office of this body is to act as an agent, exciting the 
act of deglutition. It draws the veil against the upper wall of the 
pharynx, thus closing the posterior nares during the process of swal- 
lowing. In the production of loud declamation and the guttural 
forms of language, it is supposed to modify speech by lessening the 
pharyngo-nasal passage when it acts as an elevator ; this elevating 
force being most exhibited in the highest ranges of the singing voice, 
and least in the lower keys. 

Continuing to look for a short period into the mouth, we observe 
that jets of fluid are occasionally sent up from the anterior floor just 
back of the lower central teeth. We also see drops constantly issuing 
from an orifice situated on the cheek by the side of the superior 
second molar tooth. This fluid is the salivary secretion, and comes 
from glands situated in the immediate neighborhood. Besides this 
salivary fluid, pearly drops are seen, more or less plainly, over the 
surface of the common mucous membrane. This is mucus, and is 
the product of the follicles, crypts, or glands of the common mem- 
brane. 

The mouth, then, we may say, is made up of, and invites a study 
of, the lips, cheeks, gums, teeth, mucous membrane, tongue, hard 
and soft palate, and salivary glands ; and if we accept, as indeed 
surgically we must, that the cavity begins with the lips and ends 
at the posterior wall of the pharynx, then we include in the study 
all the relations which belong to the posterior entrance. 

The lips and cheeks are alike in their composition, and are truly a 
part and parcel of each other. First, in the dissection, we have a 
layer of skin on the outside and a layer of mucous membrane on 
the inside. Removing the skin, we expose a layer of cellular fascia, 
in which is more or less fatty tissue. This superficial fascia, as it 
is called, differs from other fasciae of the same signification, in not 
being a distinct or laminated tissue. It is intimately connected with 



THE MOUTH. 



59 



the skin, and more intimately associated with the muscles. Re- 
moving this, a complex grouping of muscles is exposed, — the mus- 
cles of expression. 

The view (Fig. 19) expresses so fully the position and signification 
of these muscles that it scarcely seems necessary to enter on any 

Fig. 19. — Muscles of the Face. 




Muscles of the head and neck. 1, 2, occipitofrontal muscle : 1, its frontal belly ; 2, its 
occipital belly; 3, nasal pyramidal muscle; 4, superior, and 5, posterior auricular mus- 
cles ; 7, labio-nasal elevator; 8, elevator of the upper lip; 9, nasal compressor; 10,11, 
zygomatic muscles ; 12, masseter muscle ; 13, buccinator ; 14, depressor of the oral angle ; 
15, oral orbicular muscle; 16, elevator of the oral angle; 17, 18, depressor of the lower 
lip; 19, sterno-mastoid muscle; 20, trapezius; 21, posterior belly of the digastric and the 
stylo-hyoid muscle; 22, anterior belly of the former; 23, loop of fibrous tissue attach- 
ing the tendon of the digastric muscle to the hyoid bone; 24, omo-hyoid muscle; 25, 
sterno-hyoid ; 26, sterno-thyroid, seen to the outer side and behind the anterior belly of 
the omo-hyoid ; 27, mylo-hyoid ; 28, splenius ; 29, elevator of the scapular angle; 30, 31, 
middle and anterior scalene muscles ; 32, clavicle. 



description of them. The orbicular, or sphincter of the lips, may, 
however, be specially noted, as its influence is concerned in retract- 
ing wounds of the part. In studjnng the muscles of the face, it 
will be observed that they naturally arrange themselves into groups. 



60 



ORAL DISEASES AND SURGERY. 



Thus we have a group that are elevators, another that are depressors. 
Then groups that pertain to particular regions, as the nasal, superior 
maxillary, inferior maxillary, intermaxillary, etc. Surgically, how- 
ever, the information they possess is sufficiently elicited in com- 
prehending their general plan and arrangement. 

Situated upon, and running among these muscles, we have the 
arteries of the face. These are all branches of the external divi- 
sion of the common carotid, and will be found in the dissections 
distributed exactly as seen in the view. The facial, the third 

Fig. 20. — Arteries of the Face. 




The external carotid artery and its branches. 1, right common carotid ; 2, internal 
carotid; 3, external carotid; i, superior thyroid; 5, lingual; 6, facia] ; 7, submental ; 8, 
inferior coronary ; 9, superior coronary ; 10, muscular branches ; 11, lateral nasal artery ; 
12, angular artery ; 13, occipital artery ; 14, descending cervical ; 15, muscular branch ; 
1G, posterior auricular artery ; 17, parotid branches; 18, internal maxillary; 19, temporal; 
20, transverse facial ; 21, anterior auricular ; 22, supraorbital ; 23, middle temporal ; 24, 
anterior temporal ; 25, posterior temporal artery. 



branch of the carotid externus, is observed to cross over the lower 
jaw just in front of the masseter muscle ; and, in the subject, is seen 
to emerge from or beneath the submaxillary gland, generally pass- 
ing through its substance. Its branches are ten in number ; four 



THE MOUTH. 



61 



are offshoots from its cervical portion ; six are facial. The facial 
branches are, first, the inferior labial — which passes forward under the 
depressor anguli oris, and supplies the lower part of the lip, anasto- 
mosing with all the subjacent vessels ; the submental, inferior coro- 
nary, and inferior dental arteries. The coronaries — the second and 
third of these branches — penetrate the substance of the underlying 
muscles, and pass around the lips immediately beneath the mucous 
membrane; their pulsations may be very plainly felt; in many per- 
sons these vessels are of such large size as to render hemorrhage 
from them a matter of some trouble to control. 

Fig. 21. — The Common Carotid, with its Divisions. 




Left common carotid dividing into the external and internal carotid arteries. 1, 
common carotid artery; 2, internal carotid; 3, external carotid; 4, superior thyroid; 5, 
lingual; 6, pharyngeal artery; 7, facial; 8, inferior palatine and tonsillar arteries; 9, 
submaxillary ; 10, submental ; 11, occipital ; 12, posterior auricular ; 13, parotid branches ; 
14, internal maxillary; 15, temporal artery; 16, subclavian artery; 17, axillary; 18, ver- 
tebral artery ; 19, thyroid axis ; 20, inferior thyroid giving off the ascending cervical ; 21, 
transverse cervical ; 22, suprascapular ; 23, internal mammary artery. 



The lateralis nasi, the fourth of the branches, ascends along the 
side of the nose, supplying its alse and dorsum. The fifth, the 
angular, passes between the inner can thus and nasal bridge. It 
gives off sub-branches to the orbicularis muscle, to the lachrymal 



62 ORAL DISEASES AND SURGERY. 

sac, and to the integument of the suborbital region, and finally 
loses itself in an anastomosis with the ophthalmic artery. A point 
in the view to observe is, that the inferior and all the mesial line of 
the face is supplied by branches of a common trunk, and that this 
trunk is compressible on the lower jaw just in front of the masseter 
muscle, facial hemorrhage being thus perfectly under control by com- 
pression. 

THE NEKVES OF THE FACE. 

The view (Fig. 22) beautifull}^ exhibits the distribution of the 
branches of the facial nerve. The main trunk, seen emerging just 
below the lobe of the ear, in front of the anterior border of the sterno- 
cleido-mastoideus, is the portio dura, or hard portion of the seventh 
nerve, the motor nerve acting on the muscles of expression. The 
nerve arises from the medulla oblongata, passes outward over the cms 
cerebelli, and enters the auditory meatus with the soft or auditory 
portion ; passing to the bottom of this meatus, it enters the Fallopian 
aqueduct, follows the serpentine course of this canal until it arrives 
at the stylo-mastoid foramen, whence it emerges, as seen, upon the 
outside of the face ; while, however, in the temporal bone, the 
nerve connects with several others, and forms a ganglion, the intu- 
mescentia gangliformis, as it is called. 

Issuing from the stylo-mastoid foramen, the facial associates with 
the pneumogastric, glosso-pharyngeal, carotid plexus, auricularis 
magnus, and auriculotemporal. Passing to the face, it unites with 
the three divisions of the fifth nerve. 

In front of the ear the nerve is seen to divide into two primary 
divisions or trunks, the temporo-facial and cervico-facial. The tem- 
poral, the larger of the two, passes through the parotid gland, 
crosses the neck of the lower jaw, and divides into three sets of 
branches, distributed to the temporal, malar, and infraorbital regions. 
The cervico-facial passes downward and forward through the gland, 
and divides into buccal, supra- and inframaxillary branches. The 
manner of distribution and anastomosis is perfectly shown in the 
dissection. The facial, being a motor nerve, has its distribution 
exclusively in muscular tissue : injury to this nerve exhibits its 
results in the altered expression of the face in paralysis following its 
destruction. 



THE MOUTH. 
Eig. 22. — Nerves of the Face. 



63 




1, trunk of the nerve emerging at the stylomastoid foramen ; 2, its deep auricular 
branch ; 3, anastomosis of the latter with the great auricular nerve of the cervical 
plexus ; 4, 5, 6, branches to the contiguous muscles; 7, 8, branches of the facial to the 
digastric and stylo-hyoid muscles ; 9, temporo-facial division of the nerve ; 10, branch to 
the temple, anastomosing with the auriculo-temporal nerve ; 11, temporal branches ; 12, 
zygomatic branches ; 13, infraorbital branches ; 14, 15, cervico-facial division of the 
facial nerve ; 14, buccal branches ; 16, inferior maxillary branches ; 17, cervical branches ; 
18, auriculo-temporal nerve ; 19, 20, terminal branches of the frontal nerve ; 21, terminal 
branch of the lachrymal nerve; 22, external nasal nerve; 23, branch of the temporo- 
malar nerve; 24, terminal branch of the internal nasal nerve; 25, infraorbital nerves; 
26, anastomosis between the buccal branch of the inferior maxillary nerve and the buccal 
branches of the facial nerve ; 27, terminal branches of the inferior dental nerve ; 28, great 
occipital nerve; 29, 31, branches of the great auricular nerve; 30, small occipital nerve; 
32, superficial cervical nerve, anastomosing with the facial nerve. 



THE VEINS OE THE FACE. 

The veins of the face will be seen to correspond quite closely 
with the arterial distribution. Surgically they are, however, of 
little import, as it is seldom that wounds of them are of sufficient 



64 



ORAL DISEASES AND SURGERY. 



consequence to command any direct attention ; they pass their blood 
into one or another of the three jugulars, being not by any means 



Fig. 23. — Veins of the Face. 




Veins of the head and neck. 1, frontal vein ; 2, nasal vein ; 3, 4, labial veins ; 5, 
facial vein; 6, lingual vein; 7, internal jugular vein; 8, 9, posterior and anterior tem- 
poral veins ; 10, transverse facial vein ; 11, internal maxillary vein ; 12, posterior auricu- 
lar vein ; 13, external jugular vein; 14, posterior, 15, anterior jugular veins, er, external 
carotid artery; b, sterno-mastoid muscle; c, trapezius; d, pectoral muscle; e, deltoid 
muscle. 



constant in the selection. Between them all, however, the most 
thorough anastomosis is always found to exist, thus rendering it 



THE MOUTH. 65 

really of little consequence what may be the direct downward course 
of the current. The veins of the antero-exterior head are the facial, 
the temporal, the internal maxillary, and the temporo-maxillary. 

The facial, commencing at the inner angle of the orbit, is formed 
by the confluence of the supraorbital, palpebral, nasal, and angular 
veins. It commences its course downward and outward, passing 
beneath the zygomatic muscles, receiving the superior and inferior 
labial veins, the buccal, and the masseteric ; passes to the base of the 
jaw, receiving just below it the submental, the inferior palatine, the 
submaxillary, and the ranine veins, and, finally, with a great branch, 
received from the temporo-maxillary, loses itself in the deep jugular. 

The temporal commences by a plexus on the side of the head and 
vertex, passes downward in front of the ear, receives the transverse 
facial, posterior auricular, occipital, and deep maxillary veins, enters 
the substance of the parotid gland, and, finally, being enlarged by 
these various branches, becomes the external jugular. 

The internal or deep maxillary is, in its origin, a series of veins 
collecting the blood from the parts supplied by the internal maxil- 
lary artery and adjacent parts. These various veins, the middle 
meningeal, deep temporal, pterygoid, masseteric, buccal, and inferior 
dental, forming the common trunk, empty into the temporal. 

The temporo-maxillary is simply the name given to that part of 
the temporal vein below the point of entrance of the maxillary — 
either name is used with equal propriety. 



SECTIONAL EXPEESSION OF THE MOUTH. 

The view (Fig. 24) represents a section directly through the centre 
of the skull from before backward, and perfectly exhibits the char- 
acter of the mouth and its associations. Below is seen the tongue 
in its relations, in front, to the genial tubercles ; behind, to the epi- 
glottis. A fossa between the root of this organ and the epiglottis, 
one on each side of a common centre, the frsenum epiglottidis, is par- 
ticularly worthy of note, as it is a frequent receptacle for fish-bones 
and other foreign bodies, giving sometimes much trouble in their 
removal. The free surface of the tongue is seen to be convex, while 
the section reveals its common body to be triangular with the apex, 
looking forward. 

The roof of the mouth, seen above, is remarked to be a quite thin 
plane, forming as well the floor of the nose. Its relation to the oral 
cavity is concave, but differs widely in various persons, being in 

5 



Q6 



ORAL DISEASES AND SURGERY. 



some almost flat, in others very deep. The anterior portion, bony, 
will be recognized as being formed by the palatine processes of the 
maxillary and palate bones ; the posterior portion, soft, veil-like, and 

Fig. 24. — Sectional View of the Nose, Mouth, and Pharynx. 




SS=^30 







Vertical section of the face and neck, through the median line antero-posteriorlt, 
exposing to view the nose, mouth, pharynx, and larynx. 1, oval cartilage of the left 
nostril ; 2, triangular cartilage ; 8. line of separation between the two ; 4, prolongation of 
the oval cartilage along the column of the nose; 5, superior meatus of the nose; 6, middle 
meatus ; 7, inferior meatus ; 8, sphenoidal sinus ; 9, posterior part of the left nasal cavity, 
communicating with the pharynx ; 10, orifice of the Eustachian tube ; 11, upper extremity 
of the pharynx; 12, soft palate, ending below in the uvula; 13, interval of the mouth be- 
tween the lips and jaws ; 14, roof of the mouth, or hard palate ; 15, communication of the 
cavity of the mouth with the interval between the jaws and cheek ; 16, tongue ; 17, fibrous 
partition in the median line of the latter ; 18, genio-glossal muscle ; 19, genio-hyoid 
muscle; 20, mylo-hyoid muscle: 21, anterior half arch of the palate; 22, posterior half 
arch of the palate ; 23, tonsil ; 24, 25, floor of the fauces ; 26, 27, pharynx ; 28, cavity of 
the larynx ; 29, ventricle of the larynx ; 30, epiglottis ; 31, hyoid bone ; 32, 33, thyroid 
cartilage; 34, thyro-hyoid membrane ; 35, 36, cricoid cartilage ; 37, vocal membrane. 



movable, is the velum, terminating in the uvula in the centre, just 
above and in front of the tip of the epiglottis ; laterally, in two 



THE MOUTH. 



67 



pillars or half arches, called respectively the anterior and posterior 
pillars. The first of these — the one seen in the view as associating 
itself with the tongue — is formed by the projection of the palato- 
glossus muscle; the second, or posterior, is the projection likewise 
of a muscle, the palato-pharyngeus, passing from the veil to the 
pharynx ; the fossa existing between these pillars lodges the tonsil 
gland. The hard portion of the palate, or oral roof, is frequently the 
seat of necrosis ; it will be remarked that only a very small loss of 
substance is required to associate the two cavities. The isthmus of 
the fauces, the space between the two arches, is bounded, above, by 
the margin of the palate ; below, by the base of the tongue ; laterally, 
by the half arches and amygdalae. 

The Tonsils. — The tonsils are glandular organs, situated one on 
either side of the isthmus. These bodies are made up of many lob- 
ules, having many sulci lined by involutions of the common mucous 
membrane. They are not unfrequently the seat of such hypertrophy 
as to make necessary their amputation, while in their sulci may lodge 
debris, which, in its retention and decomposition, becomes one of the 
sources of an unpleasant breath. Externally these bodies are in 
very close relation with the internal carotid arteries, a point neces- 

Fig. 25. — Side View of the Muscles of the Tongue. 




1,2, stylo-glossal muscle; 3, lingual muscle; 4, upper part of the tongue; 5 6, hyo- 
glossal muscle ; 7, genio-glossal muscle ; 8, stylo-pharyngeal muscle ; 9, genio-hyoid mus- 
cle ; 10, 11, median line of the mylo-hyoid muscles. 



sary to be kept in remembrance in performing 
(See Tonsil Glands.) 



operations on them. 



68 



ORAL DISEASES AXD SURGERY. 



The relationship of a bolus of food with the pharynx, and its 
direction, over the chink of the glottis into the oesophagus, by the 
epiglottis, are clearly exhibited by the drawing. 

The Tongue. — Dissection of the tongue reveals it to be a some- 
what complex body, although made up in the great mass of its bulk 



Fig. 



-Upper Surface of the Toxgue. 





m 





r 



1, 2, V-like row of the cireunivallate papilla?; 3, capitate papilla?; 4, 5, conical pa- 
pilla?; 6. 6. floor of the fauces, with numerous simple follicular glands; 7, tonsils; 8, 
summit of the epiglottis ; 9. the middle glosso-epiglottic fra?num. -with depressions on each 
side bounded externally by the lateral fra?na. 



by muscular substance. Attached to the inferior maxillary bone in 
front, and to the hyoid behind, it yet moves with the greatest free- 



THE MOUTH. 69 

dom and latitude in either direction, giving us the idea that if it is 
muscular substance, it must be free muscle set upon fixed muscles, 
and this is practically the case, as is understood by studying a dis- 
section. 

The muscular structure of the tongue is made up of five distinct 
pairs and certain non-attached fasciculi. The body, as its surface is 
concerned, is seen with a base looking backward into the fauces, 
and a tip, which represents the apex of a pyramid. Beginning 
the study of the organ with its relations to the hyoid bone, we 
remark, first, that from this bone arises a muscle, the hyoglossus, 
which, passing almost directly upward, enters, with the stylo-glossus, 
the root of the body, and expands itself laterally and forward. 
Passing toward the centre of the bone, we remark a second muscle, 
the genio-hyoglossus, which, having apparent origin from the genial 
tubercles, radiates downward and upward, attaching one of its 
wings to the os hyoides, the other spreading out to assist in the 
formation of the tongue. The stylo-glossus, the third muscle, arises 
from the styloid process of the temporal bone, passes downward 
and forward, and occupies or makes up either lateral aspect from 
the tip to the bone. The fourth, the lingualis, seen between the 
stylo-glossus and genio-hyoglossus, passes from the tip to the base, 
having, indeed, some few of its fibres continued to the os hyoides. 
The fifth, the palato-glossus, is the muscle of the anterior half arch ; 
it assists in forming the base and side. The unattached fibres are 
certain longitudinal and transverse bands running through the sub- 
stance of the organ. The tongue, as an organ of nutrition, is 
adapted most happily, through its muscular character, to preside 
over the act of mastication, and, this process completed, to transfer 
the comminuted mass back into the grasp of the pharyngeal con- 
strictors. Its ability and variety of action are comprehended by a 
single moment's observation of the dissection. 

Fig. 26, exhibiting the magnified upper surface of the organ, dis- 
covers it covered with mucous membrane, dotted here and there 
with more or less regularly located papillae, of varying size and 
character. 

The mucous membrane envelops the tongue wherever the body 
has free surface. Above, it is dense, and affords support to the 
papillae; below, it is exceedingly delicate, and is traceable through 
the ducts of the submaxillary and sublingual glands. 

The papillae, seen upon the dorsum, are cone-shaped projections 
of homogeneous tissue, holding arteries, veins, and nerves in plexi- 



70 



ORAL DISEASES AND SURGERY. 



form arrangement; they are located in three distinct sets, each 
having distinctive features. 

The most posterior are the largest, and occupy a position which 
very much resembles the letter Y; they may be likened to inverted 
cones, the apices resting in cup-shaped depressions of the mucous 
membrane, hence surrounded each by a valley. They are variously 

Figs. 27 and 28 — Papilla of Tongue. 




Diagram of the papilla of the tongue, moderately magnified. 1, capitate papilla? ; 2, 
conical papilla? ; 3, epithelium ; 4, the same structure forming hunches of hair-like pro- 
cesses ; 5, connective tissue. 




Papilla of the tongue, highly magnified. 1, conical papilla? ; 2, capitate papilla? ; 3, 
simple papilla?, occupying the intervals of the compound papilla?; 4, epithelium ascend- 
ing from the conical papilla? in hair-like processes ; 5, isolated epithelial scales from the 
latter. 



named. The niaximse or circumvallatae ; of this class there are some 
fifteen ; the elevated margins of the fossa surrounding these papillae 
are studded with secondary papillae. The structure of these bodies 
is accurately exhibited in the magnified drawing. 

The papillae fungiformes or mediae are scattered somewhat irregu- 
larly over the sides and apex of the organ ; they are exceedingly 
vascular, and closely covered with secondary papillae ; are broad and 
rounded on their free surfaces, narrow and pointed at their attach- 
ment to the tongue ; their middle size and red color easily distin- 



1 



THE MOUTH. 71 

guish them. The magnified fungiform papillae are seen in the 
drawing. 

The smallest or filiform papillae follow somewhat in their arrange- 
ment the order of the maxim se, being interspersed among the fungi- 
formes. They are very minute, and covered so deeply with epithe- 
lium as to appear quite white ; they are enveloped with secondary 
papillae, as exhibited in the figure. 

In the tongue, beside these papillae are found also numerous 
mucous glands ; these bodies, scattered over the whole surface, 
secrete the ordinary mucus ; they differ in no respect from mucous 
glands w T herever situated. In the valleys surrounding the maximae 
papillae these glands are found in larger number than in any other 
portion of the organ. 

A transverse section exhibits the tongue as composed of two sym- 
metrical halves, separated from each other by a fibrous septum, each 
half consisting, as we have seen, of muscular structure, supplied 
with vessels and nerves, and having, in most cases, much interposed 
fat. 

The tongue, being an organ of both special and common sense, is 
furnished with nerves of both signification. Thus the papillae, at 
the apex and sides, are supplied w T ith the gustatory filaments from 
the third branch of the fifth nerve; the great papillae and base of the 
organ, from filaments of the glosso-pharyngeal ; the muscular struc- 
ture, from the hypoglossal. 

The arteries of the tongue are the lingual, branches of the facial, 
and ascending pharyngeal. The one of most signification is the 
first. This vessel, by its continuation known as the ranine, anasto- 
moses with its fellow, just above the fraenum, on the under surface of 
the organ, and is liable to be opened in the operation for tongue-tie. 
This artery is the second branch from the external carotid ; it pursues 
a course parallel, for a short distance, with the great horn of the hyoid 
bone lying between it and the hypoglossal nerve. Wounds of the 
tongue occasionally make the vessel at this point the seat of ligation. 

The epiglottis, seen by depressing the dorsum, forms, practically, 
the base of the organ, being supported in the centre by a bridle, the 
fraenum epiglotticlis, and at either side by two duplications of the 
lingual mucous membrane, the glosso-epi glottic ligaments or folds, 
as they are called ; these boundaries form two lateral depressions or 
fossae, fossae linguales, noticed as being so frequently the seat of the 
lodgment of foreign particles. (See Diseases of the Tongue.) 

The Gums. — See Diseases of the Gums. 



72 ORAL DISEASES AND SUBGERY. 

The Mucous Membrane. — Practically considered, the oral mucous 
membrane is to be viewed as commencing at the lips and terminating 
at the anus, so much is it in sympathy part with part. Anatomically, 
we view this membrane as consisting of a plane of homogeneous 
tissue, underlaid by its vascular supply, the vessel being supported 
by and in cellular tissue. This basement membrane gives support to 
a covering of squamae or scales, known as the epithelium, and covers 
in tissues or organs which have offices of a recrementitial nature. 

The tissues, besides the vascular, which underlie the mucous mem- 
brane, are the nerves, the lymphatics, and the papillary structure. 
The epithelium, the covering tissue, is singularly various in its char- 
acter, being in some parts columnar, in others squamous, in others 
ciliated. 

Commencing at the alveolar margin of the lower jaw, this mem- 
brane passes over the floor of the mouth, envelops the tongue on all 
its free surface, forming beneath, by its duplications, the fraenurn 
linguae ; from the back of the organ it is so reflected as to form the 
three glosso-epiglottic fraena ; from this it lines the pharynx and 
larynx, and is then continued over the digestive and respiratory 
tracks, lining, in the latter, the very terminal vesicles. 

The mucous cysts or follicles, so plentifully scattered over the 
oral mucous surface, have, as their office, the secretion of a limpid 
fluid, which is commonly to be seen standing over the membrane as 
drops of cold sweat are observed on the forehead in typhoid con- 
ditions, the two, indeed, looking very similar. The constituents of 
mucus are water, the peculiar organic principle called mucosin, and 
alkaline salts. Mucous glands are variously named, according to 
their location, as glandulae labiales, buccales, etc. 

Columnar epithelium consists of rod-like particles, crowded closely 
together, and bulged near the centre by a nucleus ; this variety is 
found in the air-passages, on the intestinal villi, in the bile duct, and 
elsewhere. The scaly is found in the alimentary tract as low as the 
stomach. The glandular seems to be a constituent of all the glands, 
being made up of particles bulky and globular. Ciliated epithelium 
is the columnar variety clothed with secondary particles. 

THE SALIYAKY GLANDS. 

The salivary glands are of the conglomerate order, and are very 
well represented by an ordinary bunch of grapes. There is, first, a 
great number of lobules, each lobule being a miniature gland ; from 



THE MOUTH. 73 

these come ducts, or channels of outlet, representing the grape- 
stems ; these are all associated with a common branch or duct, 
which is the channel of outlet into the mouth. 

The parotid, the largest of the salivary glands, is situated in the 
hollow between the external ear and ramus of the inferior maxillary 
bone. Its weight varies considerably in different individuals, the 
mean, however, being in the neighborhood of an ounce. The bound- 
ary of the gland above is the zygoma; below, a line- carried directly 
across from the angle of the jaw to the sterno-mastoid muscle. Dis- 
sected from its bed, the organ is found quite deeply seated ; it ex- 
tends above into the glenoid fossa of the os temporis, and below 
rests upon the styloid process and muscles, extending forward to the 
space between the two pterygoid muscles. The gland is exceedingly 
vascular, having imbedded in it the external carotid artery, which, 
in its substance, divides into the temporal, internal maxillary, trans- 
verse facial, and posterior auricular. The temporo-maxillary vein 
also traverses the structure, while the deep jugular and the internal 
carotid artery lie very close to its deep surface ; it is also pierced by 
the facial and great auricular nerves. Externally, the gland is 
smooth, and has its lobes protected by a covering, very similar in 
appearance to the pia mater of the brain. Upon this covering lie 
two lymphatic ganglia, the enlargement of which is often mistaken 
for disease of the gland itself. Covering the gland is the parotid 
fascia, a reflection simply of the common deep fascia of the neck, 
the platysma myoides, fascia superficialis, and skin. The gland 
empties its secretion into the mouth through a duct known as that 
of Steno. This passes across the face between the superficial fascia 
and muscles, perforating the buccinator opposite the second molar 
of the upper jaw. A line, designating the position of the duct, and 
which is most important to be remembered, is drawn from the lobe 
of the ear to the middle of the upper lip. This duct is composed of 
firm aud resisting tissue, is about the diameter of a crow-quill, and 
is some two inches in length; it consists of three coats, — an external 
or fibro-muscular, an internal or mucous, lined with ciliated epithe- 
lial scales, and a middle or cellular coat. 

The submaxillary, the second in size of the salivary glands, is 
situated beneath the lower jaw in the superior cervical, or sub- 
maxillary, triangle. The gland is somewhat of the size and shape 
of an almond-hull, and has a weight of two or three drachms ; it is 
completely enveloped by a triangular envelope, made by two leaves 
of the deep fascia attached below to the digastric tendon. Directly 



74 ' ORAL DISEASES AXD SURGERY. 

upon the gland, and within the envelope, are two lymphatic gan- 
glia, which are quite liable to take on inflammatory enlargement; 
these glands I believe to be pretty constant, as I have examined 
many subjects for them, and mostly with the common result of seeing 
them. The so-called extirpation of the submaxillary gland is, most 
generally, the removal of one of these bodies enlarged through 
inflammatory action; these ganglia may be surgically viewed as 
being strictly non-vascular, a ligature being seldom needed in 
operations upon them. The gland itself, on the contrary, is very 
vascular, the facial artery passing frequently directly through its 
substance, or so closely connected with the lower surface as to 
compel the division of it, or some of its large branches, before the 
body can be raised from its bed; the lingualis also sends branches 
to it, while its veins correspond with the arteries. The gland is 
closely in relation with the parotid, behind, and the lingual, in front, 
being separated from the first by the stylo-maxillary ligament, and 
from the latter by the mylo-hyoid muscle. The duct by which the 
gland conveys its secretion to the mouth is some two inches in 
length; it passes between the mylo-hyoid and genio-hyoid muscles, 
and opens by the side of the frasnum lingua?. It is the most common 
seat of ranula. The duct is called Wharton's duct. 

The sublingual is the smallest of the three glands; it lies directly 
beneath the mucous membrane, being between it and the mylo-hyoid 
muscle; its weight is about one drachm. The exact position of the 
gland, as it lies at the lateral aspect of the fraenum linguae, can be 
seen by raising the tip of the tongue ; its bulk will be noticed by ele- 
vating the mucous membrane, upon which its excretory ducts, some 
twenty in number, open ; these ducts are called ductus Riviniani, 
and are to be distinguished from one or more, called the Bartholin, 
opening into or near Wharton's duct The lingual gland, when dis- 
eased, may frequently be removed with very little hemorrhage. I 
have extirpated it without using a ligature. 



TEMPOROOIAXILLAKY AKTICULATIOX. 

The inferior maxillary bone articulates with the anterior portion 
of the glenoid cavity of the temporal, forming what is known as an 
arthrodial or gliding joint. The direct composition of this joint 
consists of the convex condyloid head of the maxillary bone, the 
concave surface of the glenoid fossa, interarticular fibro-cartilage, a 



THE MOUTH. 



75 



double synovial membrane, and a loose capsular ligament. (See 
engraving.) 



Figs. 29 and 30. — Vertical Section of Temporo-Maxillary Articu- 
lation. 




Vertical section of the articula- 
tion of the lower jaw. 1, is placed 
above the glenoid cavity ; 2, glenoid 
cavity; 3, interarticular cartilage di- 
viding the joint into two cavities, 4 and 
5 ; 6, an interarticular cartilage sepa- 
rated from a joint, to exhibit its form. 




External view of the temporo-maxillart 
articulation. 1, zygoma ; 2, glenoid tubercle ; 
3, ramus of the inferior maxillary bone ; 4, 
mastoid process ; 5, external lateral liga- 
ment; 6, stylo-maxillary ligament, a process 
of the cervical fascia. 



The double character of the glenoid fossa, with its fissure of 
division, its articulating eminence in front, and the cartilage-covered 
condyle of the maxillary bone, must be understood by looking at 
the bones. The view represents the parts in position and physio- 
logical relation. Above is seen the glenoid cavity; below, the con- 
dyle of the inferior maxilla ; between, the interarticular fibro-carti- 
lage, with a synovial or lubricating membrane lining each aspect of 
the joint : the back part of a common capsular ligament is also seen, 
which, when complete, would be exhibited as enveloping the whole 
joint. Back of the section, as shown in the view, is that portion of 
the cavity which lodges the upper part of the parotid gland. 

The capsular ligament is an exceedingly loose sac, very much, 
indeed, like the capsule of the humero-scapular articulation ; it is 
attached above to the circumference of the glenoid cavity, and in 
front to the articular root of the zygoma ; below, it clasps the neck 
of the bone just beneath the head. 

The interarticular fibro-cartilage is an ovoid plate placed between 
the two bones. It is supported in its position by a more or less 
perfect circumferential attachment to the common capsule, the 
external lateral ligament, and to the tendon of the external pterygoid 
muscle : below, its face is concave, corresponding with the convexity 



76 ORAL DISEASES AND SURGERY. 

of the condyle ; above, it is concave in front, convex behind, cor- 
responding with the glenoid cavity proper, and the eminentia articu- 
laris. In composition the circumference is markedly fibrous, shading 
off to a cartilaginous centre, frequently quite soft, and sometimes 
perforated. 

The synovial membranes, placed, as seen in the view, one above, 
the other below the interarticular fibro-cartilage, are the ordinary 
lubricating membranes of closed cavities ; they may very well be 
likened to two simple bags, with parietal attached faces. These 
bags secrete the synovia, a fluid which looks not unlike the white 
of an egg, but which is much more oily and resistive in its nature. 

From the spinous process, seen on the great wing of the sphenoid 
bone, a ligament, the internal lateral, descends to be attached to the 
inner face of the ramus. Behind, from the styloid process of the 
os temporis, a second, the stylo-maxillary, passes to be inserted just 
above the angle. 

The external lateral ligament is a short, somewhat triangular- 
shaped band of fibrous tissue, having origin from the zygoma ; pass- 
ing obliquely downward and backward, and inserted about the neck 
of the condyle ; just below the head, it lies in contact with the lateral 
aspect of the interarticular fibro-cartilage, and really assists in form- 
ing, or at least in thickening, the common capsule. Externally, it is 
quite superficial, being covered only by the integuments, except in 
instances where the upper border of the parotid gland spreads over 
it. The importance of the character of this articulation renders 
necessary its careful study by personal dissection. 



CHAPTER III. 



FIFTH PAIR OF NERVES. 



Fig. 31. — Section or Head, exhibiting at a Common View the Distri- 
bution of the Fifth Pair of Nerves to the Teeth. 




The fifth is an encephalic nerve, — that is, coming off from that 
portion of the cerebro-spinal centre lying within the cranium. It is 
called the fifth, because this is the order of its emergence ; also tri- 
facial, because, while within the cranium, it divides into three por- 
tions, which portions, in their divisions and subdivisions, are 
distributed respectively to the superior, middle, and inferior portions 
of the facial region; also "trigeminus," a name derived from tri, 
three, and geminus, twin, or double, signifying literally three double, 
triple, referring to its threefold divisions. 

(it) 



78 



ORAL DISEASES AND SURGERY. 



The fifth, trifacial or trigeminus, is first discovered as a number 
of filaments, of which there are two distinct sets, coming off from 
the sides of the pons Varolii ; this is called its superficial origin. 
The deep, or true origin, can be traced into the substance of the pons 
as far as the lateral tract of the medulla oblongata. These filaments 
of origin are called the roots of the nerve, and, being twofold, afford 

Fig. 32. — Trifacial Division and Ganglia. 






vi i r 



: ---- X . 

j0&~^^-~- ~— --: : ■ ..;- 

Trifacial nerve, the upper part of the orbit and temporal fossa removed. 1, semilunar 
ganglion ; 2, ophthalmic nerve ; 3, lachrymal nerve ; 4, frontal nerve ; 5, 6, its two prin- 
cipal branches ; 7, a branch passing from the orbital above the pulley of the superior 
oblique muscle; 8, nasal nerve; 9, its external nasal branch; 10, course of the internal 
nasal nerve from the orbit into the cranium and nose ; 11, 12, 13, temporal branches of 
the inferior maxillary nerve; 14, commencement of the auriculo-temporal nerve; 15, 
greater petrosal nerve. I, olfactory nerve; II, optic nerves; III, oculo-motor nerve; 
IV, pathetic nerve to the superior oblique muscle of the eye ; V, trifacial nerve ; its 
small root visible beneath the cut end of the large root, which forms the semilunar gan- 
glion dividing into the ophthalmic, superior, and inferior maxillary nerves ; VI, abdu- 
cent nerve ; VII, facial, included in a groove of the auditory nerve. VIII, both entering 
the auditory meatus; IX, glossopharyngeal, X, pneumogastric, and XI, accessory nerves 
emerging at the jugular foramen; XII, hypoglossal nerve. 



the likeness which exists between this particular encephalic nerve 
and the nerves of the spinal cord. 

The fifth nerve is peculiar in being both compound and special : 



THE FIFTH PAIR OF NERVES. 79 

that is to say, it supplies parts with filaments of sensation, with fila- 
ments of motion, and through one of its branches, called the "gusta- 
tory," with filaments which pertain to the sense of taste. It is the 
great sensitive nerve of the head and face ; the nerve of motion to 
the muscles of mastication ; the nerve of the sense of taste to the 
anterior part of the tongue. (See Function of Nerve.) 

Immediately on the emergence of the roots from the points of 
their superficial origin, they pass through a slit-like opening in the 
dura mater at the apex of the petrous portion of the temporal bone. 
Here the larger root, called the sensor, enters a ganglion, lying in a 
fossa on the anterior face of this triangular apex, the Gasserian or 
semilunar. 

The ganglion of Gasser is a small reddish-gray semilunar knot 
enveloping apparently the great or posterior root of the fifth nerve 
as it passes over the temporal apex • its size is about equal to that 
of an ordinary buckshot, although, from its flattened and crescentic 
form, the measurement from tip to tip of its horns would surpass 
somewhat the diameter of such a shot. The convex face of the gan- 
glion looks forward. 

On emerging from this ganglion, the posterior root is found 
divided into three cords, — the three primary divisions of the sensi- 
tive portion. The first of these cords constitutes what is called the 
ophthalmic nerve, or the ophthalmic portion or division of the fifth 
nerve. The second cord is the superior maxillary nerve, or superior 
maxillary division of the fifth. The third is the inferior maxillary 
nerve. 

The first of these nerves has its distribution over the orbito-frontal 
region. 

The second has its distribution over the superior maxillary 
region. 

The third associates with the lesser or motor root, which root 
first connects with it at the base of the skull, and has its distribution 
over the inferior maxillary region. 

OPHTHALMIC NEKVE. 

This division of the fifth passes from the Gasserian ganglion along 
the outer wall of the cavernous sinus, and enters the orbit through 
the sphenoidal fissure ; before entering this, however, it breaks up 
into three branches. These branches supply the eyeball, the lach- 
rymal gland, the mucous lining of the nose, and the muscles and 
the integument of the forehead. They are called frontal, lachrymal, 



80 ORAL DISEASES AND SURGERY. 

nasal. The ophthalmic is the smallest of the three divisions of the 
fifth. It is a flattened band not more than an inch in length, receiv- 
ing, before breaking up into its terminal branches, filaments from 
the carotid plexus of the sympathetic, and giving off two or more 
filaments, which, with a branch from the fourth nerve, pass between 
the layers of the tentorium. 

The Frontal Branch is the largest of the divisions of the ophthal- 
mic, and is commonly regarded as the continuation of the nerve. In 
the orbit it lies above the levator palpebrae muscle, between it and 
the periosteum, dividing about midway of the cavity into two 
branches, — supratrochlear and supraorbital. 

The supratrochlear branch passes inward to the pulley of the 
superior oblique muscle, giving off here descending filaments which 
anastomose with similar trochlear filaments from the nasal nerve. 
A second or terminal branch passes from the orbit between the 
superior oblique and supraorbital foramen, ascends behind the cor- 
rugator supercilii and occipito-frontalis muscles, to both of which it 
distributes filaments, and is finally lost in the integument of the 
forehead. 

The supraorbital branch or division of the frontal passes forward 
until it reaches the supraorbital foramen, when it passes out unto 
the forehead. In this situation it gives off a number of filaments to 
the upper eyelid, called palpebral. In its distribution over the fore- 
head, it sends branches to the orbicularis palpebrarum, occipito- 
frontalis, and corrugator supercilii muscles, anastomosing in the 
first-named muscles with filaments of the facial nerve. Other two 
sets of terminal filaments supply, the first, the periosteum covering 
the frontal and parietal bones ; the second, the integument, as far 
back as the occiput. 

The Lachrymal. — This is the smallest of the three divisions of 
the ophthalmic. It is almost always accompanied by filaments from 
the fourth nerve. In the orbit it connects itself with the orbital 
branch of the second or superior maxillary division of the fifth 
nerve. Its distribution is to the lachrymal gland, the conjunctiva, 
and the integument of the upper eyelid, in which last situation it 
joins with filaments of the facial nerve. 

The Nasal, — This division is intermediate in size between the 
frontal and lachrymal. Entering the cavity of the orbit between the 
two heads of the external rectus, it passes directly across the optic 
nerve to the anterior of the ethmoidal foramina ; through this fora- 
men it passes into the cavity of the cranium, where it traverses the 



THE FIFTH PAIR OF NERVES. 81 

shallow groove on the front of the cribriform plate of the ethmoidal 
bone, until arriving at the nasal slit it passes directly downward 
into the nose, terminating in two branches. Of these two branches, 
the external descends on the inner surface of the nasal bone, supply- 
ing the mucous membrane of its neighborhood ; leaving the cavity 
at the juncture of the bone with the lateral cartilage, it passes, on 
the external part of the nose, down to supply the integument of the 
lips, and join with the facial nerve. The second branch, the internal, 
supplies the mucous membrane about the front of the septum. 

In the orbital cavity are given off three branches from the nasal 
— the ganglionic, ciliary, and infratrochlear. 

The ganglionic is a slender cord, about half an inch in length, 
which is the sensor filament to the orbital or ophthalmic ganglion. 
(See Ganglia.) 

The ciliary separates into branchlets, called long ciliary, to distin- 
guish them from certain shorter branches, called also ciliary, given 
off from the ophthalmic ganglion. These branches are two or three 
in number, and, in association with the short ciliary, pierce the pos- 
terior face of the sclerotic, and, passing between this coat and the 
choroid, are distributed to the ciliary muscle and iris. 

The infratrochlear branch is given off just as the main portion 
passes into the ethmoid foramen, joining beneath the pulley of the 
superior oblique muscle, with a filament of the supratrochlear nerve ; 
this branch continues to the inner angle of the eye, where it is dis- 
tributed to the orbicular muscle, the integument of the eyelid, and 
side of the nose, to the conjunctiva, caruncula lachrymalis and lach- 
rymal sac. 

Recapitulation. — The ophthalmic or first division of the fifth 
nerve supplies the tentorium, lachrymal gland, caruncula lachry- 
malis, lachrymal sac, ciliary muscle and iris, muscles of eyelid and 
forehead, integument of forehead and nose, mucous membrane of 
eye and nose, and pericranium of frontal and parietal regions. 

SUPERIOR MAXILLARY NERVE. 

This nerve or division arises, as a flattened band, from the middle 
of the Gasserian ganglion. It passes forward over the greater wing 
of the sphenoid bone, until, reaching the foramen rotundum, it leaves 
the cranium, and presents itself in the spheno-maxillary fossa ; from 
this fossa it passes to the orbital cavity, through the spheno-maxil- 
lary fissure, where, being lodged in the infraorbital canal, it con- 
tinues forward to the points of its ultimate distribution. 

6 



82 



ORAL DISEASES AND SURGERY. 



Branches of Distribution. — 1. In the Spheno-maxillary Fossa. 
Three, — the orbital, the ganglionic, the posterior dental. 

The orbital enters, with the main branch of the nerve, the orbital 
cavity, and divides into two branches, temporal and malar. The 
temporal branch passes from the orbit through a foramen in the 
malar bone, and enters the temporal fossa; it here perforates the 
temporal muscle and fascia, and is distributed to the integument 

Fig. 33. — Superior Maxillary Nerve. 




The external -wall of the left orbit and of the superior maxillary bone removed. 

I, superior maxillary nerve in its course through the infraorbital canal ; 2, 3, posterior 
dental nerves; 4. anterior dental nerve; 5, anastomosis between the dental nerves; 6, 
spheno-palatine ganglion ; the branch from the superior maxillary nerve above is the 
commencement of the temporo-malar nerve; 7, pterygoid nerve; 8, greater petrosal 
nerve joining the facial nerve; 9, deep petrous nerve joining the carotid plexus of the 
sympathetic; 10, abducent nerve with its communicating branches of the latter plexus; 

II, superior cervical ganglion ; 12, ascending branches to the carotid plexus ; 13, facial 
nerve; 14, glossopharyngeal nerve; 15, the tympanic nerve; 16, branch to the carotid 
plexus; 17,18. 19, branches to the round and oval windows and Eustachian tube; 20, 
branch to the smaller petrosal nerve, 21. 

covering the side of the head, and associates with the facial nerve, 
also with an ascending branch, auriculotemporal, of the inferior 
maxillary. The malar branch leaves the orbit also through a foramen 
in the malar bone, perforates the orbicularis palpebrarum muscle, 
and joins with a branch of the facial. 

The ganglionic divides into two branches, which drop directly 
down into the spheno-palatine, or Meckel's ganglion ; hence they are 
commonly known as the spheno-palatine branches. 

The posterior dental arises from the trunk just as it enters the 
orbit; it immediately breaks up into an anterior and a posterior 
portion. The first supplies the gums and buccinator muscle; the 
second pierces the tuberosity of the maxillary bone, and, after form- 






THE FIFTH PAIR OF NERVES. . 83 

ing a minute plexus above the alveolus, distributes filaments to each 
of the posterior teeth ; its termination is lost in a union with the 
anterior dental nerve. 

2. In the Infraorbital Canal. — One, — the anterior dental. This 
branch is given off about midway of the canal. It enters a second 
canal existing on the anterior face of the maxillary sinus, and curv- 
ing backward, associates itself, as above alluded to, with the pos- 
terior dental ; from the curve are given off filaments to the anterior 
teeth, — incisors, canines, and bicuspidati. 

3. On the Face. — Three, — palpebral, nasal, labial. These are the 
terminal filaments, the division occurring as the nerve issues from 
the infraorbital foramen. The palpebral filaments pass up to the 
supply of the orbicularis palpebrarum muscle and the integument 
and conjunctiva of the lower eyelid; at the outer angle of the orbit 
they associate with the malar branch of the orbital and filaments of 
the facial nerve. The nasal filaments pass across the nose, supply- 
ing the muscles and integument of this region ; they usually join at 
the tip with the nasal branch of the ophthalmic. The labial fila- 
ments pass downward beneath the levator labii superioris, and are 
distributed to the muscles and integument of the upper lip, to the 
mucous membrane of the mouth, and to the labial glands. The 
intricate plexus situated in the canine fossa is formed of filaments 
from the facial nerve associating with twigs of the tri maxillary 
division. 

Recapitulation. — The superior maxillary nerve, or second division 
of the fifth, supplies the integument on the side of the head, Meckel's 
ganglion with its sensor filaments, the teeth, the antrum, orbicularis 
palpebrarum muscle, integument and conjunctiva of lower eyelid, 
muscle and integument of nose, muscles, integument, and mucous 
membrane of superior lip, and labial glands. 

INFERIOR MAXILLARY NERVE. 

This nerve or division is the largest of the three, and constitutes, 
justly speaking, the only portion of the fifth nerve compound in 
character The sensor portion is the third of the cords emerging 
from the Gasserian ganglion ; the motor portion is that lesser root 
alluded to as coming off from the pons Varolii ; the sensor cord falls 
quickly into the oval foramen of the sphenoid bone, through which 
it passes from the cranium. The motor cord, which has passed 
forward beneath the Gasserian ganglion, unites with the sensor just 



84 



ORAL DISEASES AND SURGERY. 



as it emerges from this foramen. Here then is made, by this union, 
a single cord, the perfected or compound inferior maxillary nerve — 
a nerve made up of filaments of motion and filaments of sensation. 
At the point of juncture of these two cords is found a little ganglion, 
the otic. (See Ganglia.) 

Fig. 34 — Interior Maxillary Nerve. 




Distribution of the inferior maxillary nerve. 1, muscular branch to the masseter 
muscle ; 2, 5, 7, branches to the temporal muscle ; 3, branch to the buccinator, anasto- 
mosing with one from the facial at 4; 6, external pterygoid muscle; 8, auriculotemporal 
nerve; 9, branches to the temple ; 10, branches to the ear; 11, its anastomosis with the 
facial; 12, lingual nerve; 13, branch to the mylo-hyoid muscle from the inferior dental 
nerve, 14; 15, branches to the teeth ; 16, terminal branches to the lower lip and chin. 

Immediately beneath the base of the skull, this compound inferior 
maxillary nerve divides into two branches, — anterior and posterior. 
Into the anterior branch pass most of the motor filaments. 

The anterior branch breaks up into five divisions, and is dis- 
tributed to the muscles of mastication. These divisions or branches 
receive names from the parts supplied by them ; they are the mas- 
seteric, buccal, deep temporal, and pterygoid. 



THE FIFTH PAIR OF NER VES. 85 

The posterior branch is the larger of the two divisions ; it sub- 
divides into three parts. These supply the inferior teeth, tongue, 
and auriculotemporal region. Hence the branches are named infe- 
rior dental, lingual, and auriculo-temporal. 

Divisions of Anterior Branch. — Masseteric. — This branch 
runs across the sigmoid notch of the inferior maxillary bone, enters 
the substance of the masseter muscle, and is distributed in it. In 
crossing the notch it occasionally gives off a filament to the articula- 
tion. 

Deep Temporal Branches. — These are two in number. They pass 
under the temporal muscle, and supply its deep surface. 

Buccal. — This branch pierces the external pterygoid muscle, 
passes beneath the coronoid process of the jaw, pierces the fibres of 
the temporal muscle, and, reaching the buccinator, divides upon it 
into a superior and inferior branch. The superior supplies the upper 
part of the muscle and the integument; the inferior, the lower part 
of the muscle and its lining mucous membrane. 

Pterygoid Branches. — Two in number, — one supplying each 
pterygoid muscle. 

Divisions op Posterior Branch. — Auriculo- Temporal. — This 
branch passes out to the inner side of the temporo-maxillary articu- 
lation, turns upward in company with the temporal artery, and, on 
emerging with this vessel from beneath the parotid gland, divides 
into two branches. The posterior of the two supplies the attrahens 
auriculae, the pinna, and the neighboring integument. The anterior 
passes upward with the terminal branches of the artery, and is dis- 
tributed to the temporal integument. Branches of communication 
exist between the auriculo-temporal nerve, the facial, and the otic 
ganglion. The articulation, the parotid gland, and the external 
auditory meatus receive nerve endowment from the auriculo-tem- 
poral. 

Lingual or Gustatory. — This branch is a nerve of special sense, 
presiding in part over the function of taste; its terminal filaments, 
as might be inferred, are distributed extensively to the papillae and 
mucous membrane of the tongue. Of the three sets of papillae, the 
filiform and fungiform, or those situated on the anterior two- thirds 
of the organ, receive the principal supply, the posterior or great 
papillae being supplied from the glosso-pharyngeal. On this account 
it was deduced that the gustatory presided over taste only as the 
anterior two-thirds of the tongue was concerned ; and this infer- 
ence has been abundantly borne out by vivisection. (See Todd and 



86 ORAL DISEASES AND SURGERY. 

Bowman's Physiology, pages 385 to 390.) In the dissection, the 
gustatory branch is seen coming off just opposite the sigmoid notch. 
In company with the inferior dental nerve, or branch, it passes down 
along the inner side of the ramus, until, leaving the dental somewhat 
above the posterior dental canal, it crosses obliquely to the side of 
the tongue, along which it pursues its way to its points of final 
termination, anastomosing at the tip of the organ with filaments of 
the hypoglossal. In its course it lies first beneath the external ptery- 
goid muscle, crosses the internal pterygoid, rests upon the superior 
constrictor of the pharjmx, and passes over Wharton's duct, where 
it reaches the apex of the tongue. In its course, branches of commu- 
nication are given off to the submaxillary ganglion and the hypo- 
glossal nerve. 

Inferior Dental Nerve or Branch. — This is the largest of the 
three divisions of the inferior maxillary nerve. Between its point 
of origin and entrance into the dental canal, it gives off a branch, 
the mylo-hyoid, distributed to the mylo-hyoid and anterior belly of 
the digastric muscles. The main portion, after entering the poste- 
rior foramen of the dental canal, pursues its way beneath the teeth, 
giving, in its course, filaments to all these organs, terminating finally 
in a branch, the mental, which passes from the canal at the mental 
foramen, and has its distribution in the muscular and cutaneous 
substance of the inferior lip. 

Recapitulation. — The inferior maxillary nerve, or third division 
of the fifth, supplies the muscles of mastication, the auriculotemporal 
region, the anterior two-thirds of the tongue, the mylo-hyoid and 
digastric muscles, the inferior teeth, and the muscles and skin of the 
lower lip. 

GANGLIA OF THE FIFTH PAIK OF NERVES. 

Associated with the fifth nerve are six ganglia : they are called 
Gasserian ; ophthalmic, lenticular, or ciliary ; Meckel's, or spheno- 
palatine ; naso-palatine, or ganglion of Cloquet; otic; submaxil- 
lary. 

Ganglion of Gasser. — This ganglion, called as frequently the 
semilunar, from its shape, is found lying in a slight depression on 
the anterior face, near the apex of the petrous portion of the tem- 
poral bone. It receives the posterior or sensor cord of the fifth 
nerve, and transmits it divided into three parts. The ganglion 
receives filaments from the carotid plexus of the sympathetic, and 



THE FIFTH PAIR OF NERVES. 87 

gives off filaments to the tentorium cerebelli, and to the dura mater 
of the middle fossa of the cranium. 

Ophthalmic, Lenticular, or Ciliary Ganglion. — This ganglion, 
as implied in its name, is found in the cavity of the orbit. It is a 
small, quadrangular, flattened body, not larger, generally, than the 
ordinary pin-head. It is situated between the external rectus muscle 

Fig 35. — Ophthalmic Ganglion — the Outer Part of the Eight Orbit 

Kemoved. 




1, optic nerve; 2, oculo-motor nerve; 3, branch to the superior straight and oblique 
muscles; 4, branch to the inferior oblique muscle; 5, abducent nerve to the external 
straight muscle ; 6, trifacial nerve, its ganglion and three principal branches ; 7, ophthal- 
mic nerve; 8, nasal nerve; 9, ophthalmic ganglion; 10, its communicating branch with 
the oculo-motor nerve; 11, do. with the ophthalmic nerve; 12, do. with the carotid 
plexus of the sympathetic ; 13, the ciliary nerves ; 14, frontal nerve. 

and optic nerve, well enveloped in the mass of fat found occupying 
this portion of the cavity. Its branches of communication are 
derived, the first, or sensor, from the nasal ; the second, or motor, 
from the third nerve ; the third, or sympathetic, from the cavernous 
plexus. Its branches of distribution are the short ciliary nerves. 
These nerves, ten or twelve in number, arise from the anterior face 
of the ganglion, being connected, as two sets of filaments, with the 
superior and inferior angles. The two sets pass forward, one being 
above, the other below the optic nerve, until, reaching the sclerotic 
coat of the eye, they penetrate this organ, and are distributed to the 
ciliary muscle and iris. 

Meckel's Ganglion — Spheno- Palatine. — This is the largest and 
most extensively connected of the cranial ganglia. Its position is 
in the spheno-maxillary fossa, immediately in front of the vidian 
foramen. In shape it is triangular, and in color reddish-gray. Its 
branches of communication are derived, the first, or sensor, from the 
superior maxillary nerve, which, as has been seen, gives to it two 



ORAL DISEASES AND SURGERY. 



filaments while crossing the fossa. The second, or motor, is derived 
from the facial nerve, or rather from the intumescentia gangliformis 
of that nerve. This branch is known as the great petrosal nerve ; it 
emerges from the Fallopian canal through the hiatus Fallopii, passes 
along the groove leading from this foramen, until, reaching the foramen 

Fig. 36. — View of the Spheno-Palatine Ganglion, the Outer Wall 
of the Left Nasal Cavity, and the Olfactory Nerve. 




1, olfactory nerve; 2, nasal branch of the ophthalmic nerve; 3, spheno-palatine gan- 
glion ; 4, 5, 6, palatine nerves ; 7, branch to the nose ; 8, nasal nerve to the outer wall of 
the nose ; 9, do. to the inner wall; 10, pterygoid nerve ; 11, facial nerve ; 12, deep petrous 
nerve joining the carotid plexus; 13, the other branch of the pterygoid is the larger 
petrosal nerve, which joins the facial. 

lacerum basis cranii, it pierces the cartilaginous substance, filling up 
this osseous break, and entering the vidian canal, associated with 
the carotid nerve, passes forward under the name of vidian to the 
ganglion. The third, or sympathetic, is derived from the carotid 
plexus through the vidian. 

The branches of distribution from this ganglion are numerous, 
and supply a portion of the orbital periosteum, the nares, the hard 
and soft palates, the half arches, the tonsil, the pharynx, etc. 

The ascending branches, two or three in number, enter the orbit 
through the spheno-maxillary fissure, and supply the periosteum. 

The descending, called palatine branches, are three in number ; 
the anterior of these, or large palatine nerve, descends through the 
posterior palatine canal, passes along the groove on the hard palate, 
and is distributed to the gums, the mucous membrane, and palatine 
glands, anastomosing back of the incisor teeth with the naso-pala- 



THE FIFTH PA IB OF NERVES, 89 

tine nerve; while in the palatine canal, filaments are given off which 
pass to the middle and inferior turbinated bones. 

The middle branch, called external palatine nerve, descends through 
the same canal as the preceding ; it distributes its filaments to the 
soft palate, to the uvula, and the tonsil. 

The posterior, called small palatine nerve, descends through the 
accessory palatine canal, and emerges back of the posterior palatine 
foramen. It is distributed to the levator palati muscle, to the soft 
palate, tonsil, and uvula. 

Coming off from the internal surface are two sets of branches ; 
these are called superior nasal and naso-palatine. 

The superior nasal, four or five in number, enter the nasal fossa by 
the spheno-palatine foramen; they supply the mucous membrane of 
the superior portion of the fossa. 

The naso-palatine enters the fossa with the other nasal nerves, 
passes across the roof of the nose, until, reaching the septum, it de- 
scends between the periosteum and mucous membrane to the ante- 
rior palatine foramen ; passing through this canal, it unites with its 
fellow of the opposite side, and distributes its filaments to the mu- 
cous membrane about the incisive fossa. 

Naso- Palatine Ganglion, or Ganglion of Cloquet. — This is simply 
the small swelling situated in the incisive fossa, the result appar- 
ently of the union of the naso-palatine nerves. The very name of 
ganglion is denied it by most writers. 

Otic Ganglion. — This is an oval flattened body, of small size, 
lying on the sensor portion of the inferior maxillary nerve, imme- 
diately beneath the oval foramen. Its branches of communication 
are: by sensor filaments, with the auriculotemporal nerve, by motor 
with the inferior maxillary nerve, and with the sympathetic by the 
plexus surrounding the middle meningeal artery. Branches of com- 
munication also exist with the glossopharyngeal, and through the 
medium of the lesser petrosal with the facial nerve. 

The branches of distribution are two in number: one to the ten- 
sor tympani, and one to the tensor palati muscles. 

Submaxillary Ganglion. — This is a small-sized circular ganglion, 
situated upon the submaxillary gland. It is connected, through 
communicating branches, with the gustatory nerve, sensor; with the 
facial, through the medium of the chorda tympani, motor ; and with 
the sympathetic by filaments from the plexus of the nervi molles. 

The branches of distribution are five or six in number ; they arise 
from the lower part of the ganglion, and supply the duct of the gland 
and mucous membrane of the floor of the mouth. 



90 ORAL DISEASES AND SURGERY. 



FUNCTION OF THE FIFTH NERVE* 

" The determination of the functions of the roots of spinal nerves 
has afforded the clue to that of the functions of the roots of the fifth 
nerve. The analogy of the smaller root of the fifth with the ante- 
rior spinal root, and of the larger one with the posterior spinal root, 
has long been admitted by anatomists. Hence an analogy of func- 
tion must be admitted, and the former must be viewed as consisting 
of motor fibres, the latter of sensitive ones; and by tracing each of 
the three great divisions of the nerve, we may determine its func- 
tion by its constitution, according as it derives its fibres from either 
root or from both. The ophthalmic and superior maxillary are com- 
posed of fibres derived exclusively from the larger root; they are, 
therefore, sensitive nerves. The inferior maxillary consists of fibres 
derived from both roots, and consequently is both motor and sensi- 
tive. Sir C. Bell, in his original exposition of the functions of this 
nerve, fell into error from having neglected to avail himself of this 
method of analyzing the constitution of each of its three divisions, 
from which he would have seen that it is the inferior maxillary alone 
which derives its fibres from both roots, and which perfectly resem- 
bles a spinal nerve in constitution. 

" The distribution of the three divisions of the fifth nerve confirms 
most amply the view of its physiology suggested by the anatomy of 
its origin. The ophthalmic and superior maxillary are distributed 
entirely to sentient surfaces, or anastomose with motor nerves (the 
facial). They supply the skin of the forehead, of the eyelids, the 
conjunctiva, the eyeball, the mucous membrane of the nostrils, the 
integuments of the face, the upper lip, the nose, the beard on the 
upper lip, the integument of the ear, the temple, and the whiskers ; 
they are the sensitive nerves to these regions. The inferior maxil- 
lary has two distinct sets of branches — the one by which the muscles 
of mastication are supplied ; the other, which go to the integuments 
of the lower lip and chin, and the beard, and the mucous membrane 
of the mouth and tongue. This nerve is, therefore, the nerve of mas- 
tication, and of sensation to the surfaces above named. 

" Repeated experiments in the hands of various physiologists, 
none of which, however, were more conclusive than those of Mayo, 
indicate the same views of function. Division of the ophthalmic or 

* See Todd and Bowman. 



THE FIFTH PAIR OF NERVES. 91 

of the superior maxillary induced loss of sensibility without muscu- 
lar paralysis, leaving only such an impairment of the motor power 
as destruction of the sensitive nerves invariably produces, by im- 
pairing the power of exact adjustment, for which a high degree of 
sensibility is necessary. But when the inferior maxillary nerve was 
cut, then both the power of mastication was destroyed on the same 
side, and the sensibility of the lower part of the face and tongue was 
lost. If the nerve were divided in the cranium, the whole side of 
the face and forehead, with the eyeball and nose, became insensible, 
and the muscles of mastication were paralyzed. Irritants might 
then be applied to the eyeball, without exciting winking, or causing 
pain, and strong stimulants might be introduced into the nostrils 
without creating the least irritation. When the trunk of the nerve 
within the cranium of an ass was irritated, the jaws closed with a 
snap from the excitation of the motor fibres, which are distributed to 
the muscles of mastication. 

" The conclusions which we draw from anatomy and from experi- 
ment are confirmed by the histories of cases in which the fifth nerve 
had been diseased. In such instances we may observe the most 
marked separation of the motor and sensitive power, when the 
larger portion only or the two superior divisions of the nerve are 
affected, and we find both motion and sensation destroyed when the 
whole trunk of the nerve is involved in the disease. It is not 
uncommon in such cases to find the eyeball totally insensible to 
every kind of stimulus, the nose quite unexcitable by the fumes of 
ammonia or the most pungent vapors, and the mucous membrane of 
the mouth so insensible to the contact of foreign matters that a mor- 
sel of food will sometimes remain between the gum and the cheek 
until it has become decomposed. The insensibility of the eyeball 
exposes it to the permanent contact of irritating particles of dust, 
etc., which excite destructive inflammation of its textures. The 
whiskers may be pulled forcibly without sensation. The muscles 
of mastication become wasted and inert, as shown by the distinct 
depression in the regions of the masseter and temporal muscles, but 
the superficial muscles, on which the play of the features depends, 
preserve their natural condition. 

" The fifth nerve may, therefore, be regarded as the motor nerve 
in mastication, and the sensitive nerve to that great surface, both 
internal and external, which belongs to the face and anterior part of 
the cranium. From its great size, and the large portion of the me- 
dulla oblongata with which it is connected, it may excite other 



92 ORAL DISEASES AND SURGERY. 

nerves which are implanted in that centre near to it. Thus it may 
be an excitor to the portio dura, as in winking; or to the respiratory 
nerves, as in dashing cold water in the face, or in sneezing. Its lin- 
gual portion distributed to the mucous membrane of the tongue is 
at once a nerve of taste, touch, and common sensibility, and its con- 
nection with the papillary structure of the red parts of the lips con- 
stitutes it a pre-eminently sensitive nerve of touch in those regions. 
" The study of the pathological conditions of this nerve illustrates 
its physiology in a highly interesting manner. In the dentition of 
children, whether primary or secondary, it is always affected, more 
or less : and in excitable states of the nervous centres, the irritation 
of it consequent upon the pressure of the teeth often gives rise to 
convulsions, the brain and spinal cord being irritated ; and we can 
often trace to such irritation, whether in infancy or in childhood, the 
foundation of epileptic seizures in subsequent years. Painful affec- 
tions of the face (neuralgia) have their seat in this nerve ; tic dou- 
loureux, for example. Many of the instances of painful affection of 
this nerve or of branches of it, which come under our observation, 
are well-marked examples of reflected sensation, the primary irrita- 
tion being conveyed to the centre by the vagus or the sympathetic 
from the stomach or intestinal canal. No one of these is so common 
as the pain over the brow, which so often follows derangement of 
stomach digestion ; and which may frequently be instantaneously re- 
moved by taking away the source of irritation, as by neutralizing free 
acid in the stomach. Frequently also the branches of this nerve, in 
greater or less number, on one or both sides, may, according to the 
humoral view, form a focus of. attraction for a morbific matter gen- 
erated in the blood, in persons exposed to the paludal poison, or in 
persons of rheumatic or gouty constitution ; in these cases, as in 
most others of similar pathology, the neuralgia occurs in parox- 
ysms of greater or less severity, each paroxysm being followed by a 
period of convalescence, which lasts, it may be supposed, until the 
morbid matter has been again accumulated in quantity sufficient to 
induce a high degree of irritation of the nerves." 



CHAPTER IY. 



DENTITION. 



The direct and associative lesions of the teeth being so common 
and so many, the study of the diseases of the mouth will naturally 
commence with these organs. 

The teeth of the human race are found to consist of two distinct 
sets. The first, small and delicate, pertain to infancy. The second, 

Fig. 37. — Deciduous Teeth of the Left Side — (After T. Bell.) 



r— — — — 


it 


' - ) . ' y~ 


Si 






m 



Deciduous teeth of the left side of the jaws. 1 and 2, incisors ; 3, cuspidati ; 4 and 5, 

molars. 

when normal, are in like manner proportioned to the strength, 
stature, and requirements of the individual. 

The first set, termed milk, deciduous, or temporary, consist of 
twenty teeth — ten in either jaw : four central incisors, four lateral 
incisors, four cuspidati, and eight molars. The second or permanent 
set are thirty-two in number — sixteen in either jaw : four central 
incisors, four lateral incisors, four cuspidati, eight bicuspidati, eight 
molars, and four dentes sapientise. The derivations of these terms 
are as follows : incisores, from the Latin verb incido, to cut ; cuspidati, 
from cuspis, a point; bicuspidati, from bi, two, and cuspis, point, hav- 

(93) 



94 



ORAL DISEASES AND SURGERY. 



ing two points ; molares, from mola, a mill ; dentes sapiential, teeth of 
wisdom, — so called from being developed in mature life. 



Fig. 






Permanent teeth of superior jaw. 

Nos. 1 and 2 of Fig. 38 represent the incisor teeth of the upper 
jaw, and Nos. 1 and 2 of Fig. 39, the incisor teeth of the lower jaw. 
These teeth may be described as possessed of chisel-shaped bodies rest- 
ing upon conoidal roots ; or viewed from the surgical aspect, they are to 
be considered as two cones, the bases of which abut just beneath the 
free margin of the gum. In number, the incisor teeth are eight — four 




Permanent teeth of inferior jaw. 

above and four below ; these are classified as central and lateral. The 
central incisors of the upper maxilla are fully one-third greater in 
breadth, and, indeed, in general bulk, than the lateral ; a condition 
found reversed in the inferior jaw, where the laterals are larger 
than the central, although not to the same extent of difference as 
above. In length, the superior central teeth are, on the average, 
one inch ; the laterals of the same jaw, from one-third to a fourth 
less. Below, while the depths of the crowns are found to cor- 
respond, the root of the lateral is a trifle longer. The crowns of 
the superior incisors are slightly convex in front, markedly con- 
cave behind, often, indeed, having on this face a central depression, 



DENTITION. 



95 



which, from imperfection in the enamel covering, frequently becomes 
the seat of caries. The inferior incisors, both central and lateral, 
partake more of the wedge shape. The enamel of the incisors, 
being most markedly exhibited in the superior centrals, is thickest 
at the cutting face, and gradually declines toward the neck, where it 
terminates in an abrupt line of convex aspect in front and behind, the 
convexitv looking toward the root. At the sides, the enamel forms 




Lateral view of the upper and lower permanent teeth. 1, first incisors; 2, canines ; 
3, first premolars ; 4, middle molars. 

a concave line, the concavity looking toward the free edge. The 
line of the enamel corresponds with the periosteal relation, and in 
the firmness of the ring-like fibres of this tissue exhibits the con- 
centration of the sac, which, before the eruption of the teeth, en- 
velops the whole crown, only a portion of which has been absorbed 
in the eruptive act. 

The Cuspidati — canines, eye, stomach (3) teeth — represent the 
carnivorous expression in our species. These bodies, spear-shaped in 
general form, terminating in an obtuse point, are convex in front, 
and are apt to vary in shape behind. Very strong and fixed, they 
serve the lower animals in seizing and tearing their prey. The 
roots are the longest of all the teeth, and are very slightly flattened 
cones. The superior of these teeth are called eye teeth ; the infe- 
rior, stomach teeth. 



96 



ORAL DISEASES AND SURGERY. 



Fig. 41. 






,. 






I 



The Bicuspidati — premolars — (4 and 5) have rounded crowns, 
with a double-cusped grinding surface and intervening sulcus. The 
roots of these teeth are decidedly flattened, and in the anterior are 

apt to have a longitudinal division which 
frequently separates the single fang into 
two parts. Occasionally, though very 
rarely, these teeth will be found to have 
three distinct roots. 

The Molars (6 and *7) have crowns 
of cuboid shape, are four-cusped, and 
roughened, for purposes of trituration. 
The superior have each three conoidal 
roots ; two of these are situated antero- 
posteriorly; the third, somewhat flat- 
tened, looks toward the palatine aspect. 
The inferior have two roots, the inter- 
space being buccal and lingual. 

The Dentes Sapientise (8) are in re- 
ality the third molars ; they differ, how- 
ever, in being somewhat smaller, and in 
having commonly but a single root, al- 
though this root may be recognized as a 
blending of the roots distinguishing the 
other molars. It commonly curves back- 
ward. 

The names of the teeth, expressed in 
the singular number, are, incisor, cuspi- 
datus, bicuspidatus, molar, dens sa- 
pientise. 

Figs. 41 and 42 show teeth in sec- 
tion. In the centre is a cavity, occu- 
pied by a pulp, the tooth-pulp : that 
which is its analogue, a periodonteum, 
envelops the roots. These membranes 
are the nutrient vehicles of the organ, holding and conveying the 
blood-vessels and nerves. Variations in the shape and relationship 
of the pulp cavity are matters of surgical interest, as not unfre- 
quently a near approach to the neighborhood of the surface allows 
its exposure by a very limited caries. 

A tooth is divided into three parts : a crown, root or fang, and 
neck. The crown of a tooth is the exposed part ; the fang, the part 



Vertical section of a molar tooth, 
moderately magnified. 1, enamel, 
the lines of which indicate the ar- 
rangement of its columns; 2, den- 
tine, the lines indicating the course 
of its tubules ; 3, thin lamina of the 
dentine forming the wall of the pulp 
cavity, the dots indicating the ori- 
fices of the dentinal tubules; 4, 
cement. 

Fig. 42. 




Transverse section of a molar 
tooth of the natural size. (The cut 
is made through the body of the 
tooth.) 1, dentine; 2, enamel; 3, 
cavity. 



DENTITION. 



97 



Fig. 43. 



which associates it with the jaw ; the neck, the intermediate part. 
A tooth is composed of five structures: 1, pulp; 2, dentine; 3, 
enamel ; 4, crusta petrosa, or cementum ; 5, periodonteum. 

In the centre of the section (Fig. 43) is exhib- 
ited the pulp enlarged by the microscope : this 
body is shown to be a mass of delicate con- 
nective tissue, in which ramify blood-vessels 
and nerve-filaments. See Figs. 44, 45. It 
has no enveloping membrane proper, as will 
be understood in the study of odontogeny; 
it is the original papilla, or tooth germ. 
Through the vessels of this body, the inter- 
nal structure of the tooth is nourished ; in 
its death the tooth loses its translucency, 
becoming discolored and opaque, — being, 
indeed, devitalized, except as nourishment is 
received from the periodonteum. The pulp 
of a tooth is so highly endowed with nerve- 
matter that the slightest touch suffices to pro- 
voke the most exquisite pain. 

Dentine. — The dentine, or dentinal portion 
of the tooth, is marked 2 in the diagram 
(Fig. 43). This substance is called, also, the 
ivory. While histological dispute exists as 
to the real constitution of this structure, a 
full surgical signification is found in accepting 
it as a fibro-calcareous stroma, tubular in 
character. These tubuli, commencing at the 

enamel membrane, the original tunica propria (see Dentition), ap- 
proach the pulp, opening into the cavity by capillary mouths, and 
thus receive the halitus which is their nutrition. The tubuli of 
dentine are in some instances almost straight, at other times curvi- 
linear. In the neighborhood of the enamel they are dichotomous 
and trichotomous. Figs. 46 and 4T show these varieties of tubes. 
Fig. 49 shows the tubes in transverse section. (For mode of forma- 
tion of dentine, see author's views on Dentition.) 

Enamel. — No. 3, Fig. 43, exhibits the position and relation 
of the enamel as a cap to the crown portion of the tooth. This 
structure is almost entirely inorganic in its composition, containing 
but about two per cent, of animal or living matter ; it is hard, flinty, 
brittle, and decreases in thickness as it passes from the cutting 




Vertical section of a cuspid 
tooth. 



98 



ORAL DISEASES AND SURGERY. 



face to the neck of the tooth. In composition, enamel is made up 
of a series of hexagonal fibres, having a double direction, by which 



Fig. 44. 




Dental pulp, magnified. 



Fig. 45. 




each becomes strengthened by its fellow as it is crossed and recrossed, 
one set undulating: outward, another crosswise. The nutrition of 



Tig. 46. 




1, tubuli of dentine ; 2, enamel. 

the enamel is received through the tunica propria. (See Dentition.) 
Cementum, or Crusta Petrdsa.—Tig. 43 (1) exhibits the rela- 

Fig. 47. 




Vertical section of the fang of A canine tooth, exhibiting the structure of the den- 
tine and cement. 1, inner extremities of the dentinal tubules ; 2, outer extremities of 
the tubules, terminating in interspaces at the boundary of the dentine; 3, cement; 4, 
lacunae like those of bone. Highly magnified. 



DENTITION. 



99 



tion of the cement as a sheathing to the fang. This structure so 
closely resembles bone proper as to be liable to the diseases of that 



Fig. 48. 




Three enamel columns, highly magnified ; 
exhibiting the six-sided prismatic and waving 
character. 



Fig. 49. 




Section of enamel, highly magnified, at right 
angles to the course of its columns; exhibit- 
ing the six-sided character of the latter. 



structure, and possesses all its chemical elements. A thick cemen- 
tum contains well-marked Haversian canals and Purkinjean corpus- 
cles or lakelets. (See manner of its formation in Dentition.) 

Periodonteum. — This is the analogue of the periostea of the com- 
mon osseous structures. It is a composition of fibrous tissue, serving 
the double purpose of attaching the teeth to their alveoli and support- 
ing the external vessels of nu- 
trition. At the neck of a tooth Fig. 50. 
it is found dense and resist- 
ing ; toward the apex it atten- 
uates to softness and delicacy. 

Interglobular spaces. — Fig. 
50 exhibits what are termed 
interglobular spaces, as seen 
in the dentine of certain teeth : 
these spaces possess much sur- 
gical interest, as it is to be 
presumed they represent an 
imperfect development, and 
thus explain the rapid break- 
ing down of many teeth. In 
an exhaustive paper on this 
subject, by Dr. J. H. McQuil- 
len (see Dental Cosmos, vol. 
viii. p. 113), that gentleman 
remarks, " As evideuce of the 

practical bearings of these investigations, it may be well to direct 
attention to the fact that the existence of the spaces in teeth which 
have completed their growth must be regarded as an abnormal condi- 




Interglobular spaces. 



100 ORAL DISEASES AND SURGERY. 

Hon, predisposing such teeth to decay, and that when, either by 
mechanical action, as by a fall or blow, or by the penetration of 
external caries, such spaces are reached, the disease here icould run 
riot ; hence the importance of care on the part of patients and oper- 
ators to have the most minute cavities filled ; for though reached only 
through a microscopical opening, the result would be the same, 
while, if protected from the action of external influences or the ex- 
citing causes of decay, this predisposition might remain dormant 
for a lifetime, as is sometimes the case with other diseases." 

Relation of the Teeth with the Jaw. — The teeth associate with 
the jaw through the intervention of a peculiar cellular bone described 
as the alveolar processes. This structure, as has been seen, is hol- 
lowed into pits corresponding with the shape of the roots accom- 
modated by them. In some persons this process is very spongy, 
in others it almost resembles in density the cortical portion of the 
bone ; in proportion to this density are teeth found loosely or firmly 
fixed, and it is also a matter of experience that in proportion as this 
process is solid are the teeth resistive of disease. This arises, of 
course, from these organs corresponding with the nature of the 
bone, and being to such extent isolated from systemic impressions. 
No stronger proof could be afforded of the constitutional or vital 
relationship of caries. 

We may from such general consideration pass to an examination 
of the subject of the process of the development and growth of the 
teeth. 



CHAPTER V. 



DENTITION — CONTINUED. 



In the foetus of six weeks is to be observed, at the border of the 
palate, a groove occupying the position of the future teeth. This 
groove is called the primitive dental ; scattered along the bottom of 
it are certain fine papillae, which, in their development, are found 
gradually to assume the shape of the crowns of teeth. As these 
papillae grow, the groove is converted into a series of distinct folli- 
cles for their accommodation by the growth of septi between the 
papillae, which septi soon begin to ossify, to assist in forming the 
bony sac or alveolus common to the perfected teeth. It is seen, 
however, that the septi complete only a circumferential boundary, 
the summit of the papilla being exposed. Before, however, the 
papilla has assumed the form of the tooth, the upper soft margin of 
the pit enlarges and falls over, forming an operculum or lid. 

The tooth thus forming is generally regarded as a cutaneous 
production, and would seem to be a modification of the hair or 
nail. If such inference is an error, and this body is not such a 
production, it is plainly enough seen that the papilla, being sub- 
mucous, enveloped or overlaid by the mucous membrane lining 
the primitive groove, must, in its development, either rupture this 
envelope, or assume and modify it. Now, what is the state of the 
case ? According to the observations of Goodsir, and the opinion 
of Todd and Bowman, " the tooth papilla must be regarded as 
homologous with, or answering to, the tactile and hair papillae of the 
skin, and it would therefore be expected that its main part would 
consist of a peculiar submucous tissue, covered by a homogeneous 
basement membrane, and surmounted by a tissue answering to the 
epithelium. The substance of the papilla is, at first, a congeries of 
granular nuclei, dispersed irregularly through a firm, homogeneous, 
subgranular matrix or blastema, in which vessels and nerves are 
by degrees developed This is bounded by a definite transparent 
membrane, on which rests a reflection of the epithelium lining the 
sac, modified in structure so as to present a series of columnar, 

(101) 



102 ORAL DISEASES AND SURGERY. 

nucleated particles, the matrix of the future enamel." It would 
appear, according to these observers, that the lining and reflected 
layers of the epithelium become blended together, and constitute but 
'one, which is more adherent to the sac than to the papilla; so that 
on opening the sac its walls generally seem unattached to the surface 
of the papilla, and the latter to be limited to what has been regarded 
as the basement membrane. 

The growth of the papilla, thus circumstanced, is considered by 
these authors as follows: " Between. the columnar epithelium lining 
the sac and the surface of the alveolar cavity, that is, apparently in 
the wall of the sac itself, is found a thick, semi-transparent, pulpy 
tissue, which has been termed the enamel pulp. It presents toward 
the pulp of the tooth — that is, toward the original papilla — a series 
of elevations and depressions precisely the reverse of those of the 
dentinal pulp on which they rest, and answering mutually to these, 
with only the columnar epithelium intervening. The structure of 
this pulpy tissue is elastic, spongy, loaded with fluid albumen, but 
destitute of vessels. 

" In a vertical section of these parts, the enamel pulp is seen 
covered with columnar epithelium, the enamel matrix on the surface 
toward the dentinal or tooth pulp; while on the opposite surface 
the blood-vessels of the membrane lining the alveolus are seen 
coming up to and forming loops immediately under the enamel 
pulp, without penetrating it. It is further remarkable that short 
tubes, filled with glandular epithelium, descend among these vessels 
from the enamel pulp, and end by blind extremities. How these 
tubes, which are evidently glandular, can discharge their contents, 
it is difficult to understand, seeing they appear to open into the sub- 
stance of the enamel pulp. 

" The next stage* is that of ossification; and the earthy matter is 
first deposited in the homogeneous membrane forming the dentinal 
pulp. The most prominent portions of the crown are the first to 
harden; and the ossification proceeds inward by the gradual conver- 
sion of the pulp into the dentine or ivory. The nucleated particles of 
the pulp nearest the ossifying surface are found arranging themselves 
in series vertical to that surface; and it appears that, in order to 
form these vertical series, they multiply by transverse division, 
much as those of bone cartilage are found to do. The earthy matters 
are then deposited in the indistinct cells surrounding the nuclei, so 

* Observations of Goodsir, Todd and Bowman, continued. 



DENTITION. 103 

as to form the hard and dense walls of the dentinal tubes, as well 
as the intercellular substance, so as to form the intertubular tissue of 
the perfect tooth. The cells unite endwise, and their nuclei elongate 
and coalesce in a manner to constitute the cavities of the tubes, and 
so as often to retain this mode of origin in their permanent form. 

" The calcification of the enamel commences on the surface of the 
dentine in contact with that primary osseous sheet formed from the 
basement membrane of the dentinal pulp. On this primary layer 
are minute shallow cups, closely aggregated, answering to the ends 
of the enamel columns and receiving them in a firmly cemented 
union, as the consolidation of the elementary cells proceeds. The 
enamel columns at a very early stage seem to consist only of a 
single series of nucleated particles, intervening between the dentine 
and enamel pulp. Those of the new row arrange themselves end- 
wise on the others, which they resemble in all respects, so that the 
enamel attains its proper thickness rather by the superposition of 
particle or particles successively deposited, and by the subsequent 
calcification of each in its turn, than by the development of its parts 
by an interstitial increase ; and thus it appears to differ from t*he 
dentinal pulp and to resemble the epithelium, to which it is allied. 

" It is from that surface of the enamel pulp which looks toward 
the tooth that this successive development of new enamel columns 
proceeds ; as they form, this tissue wastes ; but it is not probable 
that the pulp is converted into the columns, as the dentinal pulp is 
converted into dentine, because the anatomical characters of the 
pulp are so dissimilar from those of the columns. When first calci- 
fied, the enamel rods are loosely aggregated, and easily separate 
from one another under pressure ; but they gradually become so 
consolidated by the advance of the calcifying process in their inter- 
stices, as to make the finished enamel the most hard and indestruc- 
tible of all the products of organization. 

"The development of the layer containing the ordinary lacunae 
of bone, and which in the human teeth covers the fang, and is con- 
tinued a little way within the cavity of the root, does not seem to 
have been as accurately studied as that of the dentine and enamel. 
There can be little doubt that a membranous matrix, probably like 
that of the cranial bones, is laid down as the fang is developed, in 
which the usual steps of ossification precede the lacunas and their 
canaliculi, being formed from the corpuscles of the temporary matrix. 

"When the ossification of the dentine is so far advanced that the 
tooth can sustain with impunity the pressure to which it is destined, 



104 ORAL DISEASES AND SURGERY. 

and when the enamel is densely calcified, the eruptive stage occurs, 
in which the tooth makes its way through the gum. This is due 
to the same law of development which governs the form and position 
of other organs. The gum over the sac is absorbed, and the crown 
of the tooth is forced upward against it, chiefly by the increasing 
size of the fang below. 

" As the development of the teeth proceeds, does that also of the 
alveoli: so that by the time the teeth emerge through the gums, 
their walls are sufficiently strong and embrace the necks with firm- 
ness enough to furnish a solid basis of support. Their vascular 
canals are developed, and especially those which convey to each 
tooth its interior supply of vessels and nerves. The gums and alveoli 
are likewise provided with vessels which play their part in the devel- 
opment and subsequent nutrition of the organs." 

These are the views of development entertained by the authors 
above mentioned. The later writers — Beale, Huxley, Tomes, etc. 
— I have not quoted, because a review renders it sufficiently evi- 
dent that no one of them is fixed in his deductions or conclusions. 
Investigations made by myself in the direction have seemed to me 
to simplify the matter very much, and, indeed, to deprive it of a 
very great share of its obscurity. Whether these views may be 
nearer right than the various others held, the physiologist may for 
himself determine. I must be allowed to admit that I deem them 
irrefutable. 

At a certain period of fetal 'life, as has been remarked, a groove is 
observed, the progressive development of which proves it to be the 
primitive dental groove. This groove is lined by a delicate mem- 
brane continuous with the mucous membrane, indeed a part of it, — 
modified, but still of it, just as the conjunctival cells which pass over 
the cornea are really part and parcel of the common ocular conjunc- 
tiva. This membrane, at points corresponding with the position of 
future teeth, is seen to be elevated into little hills. A section through 
the membrane, over any of these hills, exposes a papilla. This papilla 
or body, closely examined, is found to be made up of a congeries 
of granular nuclei, dispersed irregularly through a firm homoge- 
neous blastema. This papilla is the rudiment of a future tooth, as 
observation of its development proves. It is not inclosed in a 
cell-wall or membrane of its own, but is a hyaloid structure or 
substance. The body, thus understood, is seen to lie beneath the 






DENTITION. 105 

% 

mucous membrane ; and in this membrane resides a certain amount 
of elasticity. As the papilla enlarges and projects itself, it becomes 
inclosed to all the extent possible with this mucous membrane con- 
tracted about the body so as to constitute a sac or cell wall, pre- 
cisely as the parietal peritoneum contracts about and makes a sac 
to the projected intestine in hernia. This sac enveloping the papilla 
has its continuation, as is seen, necessarily over the sides of the 
groove ; as, then, this groove enlarges and deepens, and finally en- 
velops the papilla, it is seen that the body or tooth germ gets a 
second sac. It is as though one should envelop his head in a double 
night-cap, and then bind over this a handkerchief, — the submucous 
structure of the lateral walls and operculum representing the hand- 
kerchief. 

At this period, the pulp, or original papilla, having attained the 
size of the tooth it represents, commences the process of the forma- 
tion of dentine. Before the attainment to full size of the papilla, 
there existed between it and its sac proper a halitus or fluid. This 
halitus, now that the congeries of cytoblasts or nucleated granules 
have obtained'their full growth and secretive power, is replaced by 
a more highly endowed secretion, the work of these matured cells. 
This secretion, deposited against the inner sac, or between it and 
the pulp, contains the elements of the dentinal structure, is, indeed, 
the dentine, and deposits layer after layer, supported by and moulded 
into form by the sac. Calcification is progressive with its formation. 

As this deposit intrudes on the pulp, so this body contracts within 
itself, until, finally, by some law of nature, it stops at that certain 
point which maintains within the tooth a canal or cavity, and a vas- 
cular and nervous pulp to occupy it, — this pulp being the contracted 
original papilla ; the vessels of this papilla are vessels entirely analo- 
gous to any one of the ordinary papillae of touch, so supplied and so 
maintained. 

Why this secretion, in its organization, should assume the position 
of the elongated tubular cells which pertain to the structure of 
dentine, I have of course no idea, and it is quite enough for our 
purpose to say that it is a law of form perhaps not to be compre- 
hended, and the discovery of which would, at any rate, have but 
little practical signification to us. 

The formation of the dentine completed, the covering of it with 
enamel begins; or rather this deposit is, to a degree, coincident with 
the dentinal formation. Secreted by the same pulp which formed 
the dentine, the same secretion, some portion finds its way into and 



106 ORAL DISEASES AND SURGERY. 

through the primary sac. As it passes through this sac it is modi- 
fied, receives new elements, perhaps, which, as it is received into the 
second space, or the space between the first and second caps, im- 
presses upon it the arrangement of its particles after the hexagonal 
order of the enamel. Between the enamel, thus formed, and the 
dentine, exists the primary sac; simply the originally modified 
mucous membrane, which we first saw as overlying the papilla. This 
membrane continues its existence between these two hard bodies, 
and receives and modifies, for the support of the enamel, the liquor 
sanguinis exuded from the dentinal tubules and intertubular struc- 
ture. It may be called the enamel membrane. It has, of course, 
been much modified; it is from it that we receive the impressions 
of pain when becoming exposed by a break in the continuity of 
enamel. The views propounded and exhibited by Mr. Tomes of the 
primary calcification of a membrane covering the dental pulp, and 
which, by his assertion, forms the exterior of the dentine, can only 
be a microscopical fallacy. A membrane does, without doubt, exist, 
but it is the delicate tunica propria, and it becomes calcified only 
pathologically, and, when calcified, the enamel becomes brittle and 
dead, as thus its nutrition is cut off. 

The growth of the root of a tooth, as its dentine is concerned, 
has precisely the history of the body. It is associated with the 
pyramidal elongation of the papilla or pulp, which, pushing upward 
the crown, elongates upon itself the enamel membrane. This elonga- 
tion, with a greater vascularity and vitality assumed by the mem- 
brane as it approaches the basement vessels, modifies again the 
result obtained by the exudate passing through it from the dentinal 
pulp, the result being a nearer approach to true bone in the produc- 
tion of cementum. 

The Periodonteum is the modified external sac, lost, of course, 
above the neck, as the tooth has emerged through it. 

This is a very simple and easily understood explanation of tooth 
growth. The observations leading to the conclusions have been 
somewhat extensive, and the phenomena seem certainly indorsed by 
general physiological analogy. 

We pass here to what infinitely more concerns us as practitioners, 
— namely, the relations of the first and second dentitions. 

Of the first set, the papillae of the anterior molars appear first, the 
canines and incisors next, and the posterior molars last. About the 



DENTITION. 



107 



fourth month these papillae are all in their saccular envelopes, and 
forming behind the lids of the sacs are little crescentic depressions, 
called cavities of reserve, lined with mucous membrane, and con- 
taining the germs of the papillse of the second set of teeth, — one 
to each deciduous germ. The first molar of the permanent set 
is markedly related to the deciduous, by having a common origin 
from and in the primitive dental groove ; from sacs, secondary to 
the capsule of this tooth, spring the reserve cavities of the second 
and third molars of the second set. 



Fig. 51. 




Diagram of the mode of development of the teeth, a, section across the dental 
groove ; b, papilla developed in the latter ; c, the groove deepened and processes forming 
which ultimately close it ; d, the groove becoming closed ; e, dental sac containing a 
dental pnlp, which is the rudiment of the crown of a temporary incisor ; the cavity above 
is reserved for a permanent incisor ; /, the crown of the temporary incisor fully formed, 
and the reserved cavity for the permanent tooth moving backward ; g, fang of the tem- 
porary incisor produced, and origin of the dental papilla of the future permanent tooth ; 
h, eruption of the temporary incisor, and the alveoli produced for both teeth ; i, the tem- 
porary incisor occupying its functional position, and the crown of the permanent incisor 
developed. 

The eruption of the temporary set, although more or less irregular, 
ensues, as a rule, in the following order and time, — the lower teeth 
erupting first : the central incisors about the seventh month, the 
lateral incisors about the eighth month, the anterior molars about 
the thirteenth month, the canines about the sixteenth month, and 
the posterior molars about the twenty-fourth month. The age 
intervening between the first and the last eruption is considered the 
critical period in infantile existence. (See chapter on Associated 
Lesions of First Dentition.) 



108 ORAL DISEASES AND SURGERY. 

The ossification of the permanent teeth commences, just before 
birth, with the anterior molars, proceeding forward, but terminating 
with the premolars at about the third year ; this description does not, 
however, include the posterior molars, which are really the last to 
ossify. 

The position of the permanent papillas, which at first are situated 
between the sacs of the deciduous and the gum, gradually recedes 
behind, falling deeper and deeper, at least relatively so, as the milk 
set elongates; until, on the completion of growth in the deciduous, 
the germs of the permanent set are found in the common alveoli at 
the apices of these cavities, occupying, indeed, almost the position 
and physiological relations of the original papillae. 

At this period, whenever it may be, and it varies of course with 
different individuals, commences a process of antagonism : it is 
intended that the new shall advance and increase, that the old shall 
decline and diminish. The relative position of the two bodies is as 
follows : extending to the apices of the alveoli, and receiving at these 
apices the principal vessels of nutrition, are the perfected roots of 
the first teeth. Crowding down into these alveoli, with nutritious 
vessels of their own, possessed with the high vitality of growing 
bodies, are the pulps of the second teeth. As these pulps enlarge, 
so is there a corresponding enlargement in the alveoli containing 
them, until, finally, through such process of absorption they have 
fallen directly beneath the roots of the first set. Of course a pressure 
has been equally exerted upon these roots, and, as a result, the 
nutrient vessels passing into the pulp cavities, through the fora- 
mina at the apices, have been gradually obliterated. But do the 
pulps of the milk teeth die ? Not at all ; or at least not necessarily. 
The neighboring vascularity is very great, the requirements of the 
organ very small ; a sufficient supply is received from the circulation 
in the dentine, as well as from the periodonteum, which, to the last, 
continues to close in the enlarging foramina. But this does occur: 
the absorbent or destructive system has been given the mastery, 
and little by little, day by day, and month by month, the roots of 
the first teeth disappear, while the crowns of the second advance, 
and occupy the space gained, until at length, as is witnessed every 
day, the milk tooth drops out of the cavity, minus a root, while the 
crown of the permanent is seen in its place. 

If here we take up this thrown-off tooth, we shall find that the 
pulp chamber, or what remains of it, instead of having an almost 
complete bony envelope, as is the case in the perfect organ, has 



DENTITION. 



109 



communicated more and more largely, for a varying period, with 
the soft parts, guarding us, in such knowledge, against a treatment 
in aching milk teeth, at certain periods, which would be most appli- 
cable at others. 

To judge of the condition of the foramina of the first teeth, we 
compare them with periods of eruption of the second, recognizing 
that the enlargement, or absorption, corresponds with such advance 
in the permanent. 

The first teeth of the second set erupt entirely back of the tem- 
porary, and in no way interfere with them. These are the anterior 
or first molars, and appear commonly at about the sixth year, 
seldom earlier, but not unfrequently from one to several months 
later ; the sixth year, however, is the rule. The second teeth to 
appear are the central incisors, the lower a little in advance of 
the upper — about the seventh year ; the third, the lateral incisors, 
at the eighth year ; the fourth, the anterior premolars, at the ninth 
year; the fifth, the posterior premolars, at the tenth year; the sixth, 
the canines or cuspidati, at the eleventh year; the seventh, the 
second molars, at the twelfth year; and the last, the third molars or 
wisdom teeth, at a period varying from the seventeenth to the twenty- 
fifth year — more commonly, however, about the eighteenth year. 

The teeth, in their eruption, arrange themselves in a physiological 
regularity in the arches which have enlarged for their accommoda- 
tion through a process of elon- 
gatory and interstitial growth ; 
if development and functional 
harmony have not been inter- 
fered with, the fully-grown or- 
gans are found occupying in 
regular relations the two jaws, 
yielding perfect occlusion and 
articulation. (See Associate 
Lesions.) 

Articulation. (See Fig. 1.) — 
In examining the articulated 
skull, it is seen that the six 
upper front teeth close over and 
in front of those of the inferior 
jaw, while the external tubercles 

of the bicuspidati and molars of the lower jaw lodge in the sulci be- 
tween the external and internal tubercles of those of the upper jaw ; 




First and 



econd dentition, upper and lower 
maxillae 



110 ORAL DISEASES AND SURGERY. 

thus, in the articulation, placing the external tubercles of the upper 
teeth external to the outer tubercles of the lower. The central incisor 
of the upper jaw, because of its greater width, closes not only over 
the inferior central, but overrides the lateral. The superior lateral 
overrides the cuspid ; the cuspid its fellow and the first premolar. 
The premolars override their fellows and the anterior third of the 
first molar. The first molar opposes the anterior third of the second 
molar and the posterior two-thirds of the first. The second molar 
opposes the posterior two-thirds of the second molar, and the ante- 
rior third of the wisdom tooth. The wisdom tooth of the upper jaw, 
being smaller than that of the lower, finds accommodation in antag- 
onism by the portion of its fellow left unoccupied by the second 
molar. Thus it is seen that no two teeth exclusively oppose each 
other, — an admirable provision, which not only guards as much as 
seems possible against loss of the organs from lack of antagonism, 
but secures the fullest results in the trituration of the food, 



CHAPTER VI. 

ASSOCIATIVE LESIONS OF FIRST DENTITION. 

Although it comes not strictly within the province of a work on 
surgery to treat of the associative lesions of the first dentition, yet 
it would seem that such a work could not be at all complete without, 
at least, reasonable reference to such conditions. 

When one considers the delicate and susceptible organism of an 
infant human being, and the fact of its usherance into a world where 
active causes of disease are in constant antagonism to it, he is very 
well prepared to understand that in the influence of the process of 
dentition must necessarily exist a powerful predisposing cause in- 
viting to attack, and, indeed, opening the portals, as it were, to 
enemies that otherwise might have passed harmlessly by. 

The calculations of Dr. Arbuthnot that, at this period, one in 
every ten children has its life destroyed through the associative 
and influenced lesions of the age, may, perhaps, not be strictty in 
accordance with statistics at large ; but the mortality is so alarm- 
ingly great that, to the general practitioner, no subject offers in its 
study more important and vital interests. Professor Camper is 
authority for the statement that out of 5989 infants admitted into 
foundling-hospitals, only 884 were found alive at the end of the fifth 
year. 

In the first place, we have to remark that the process of dentition, 
while a physiological one, is yet, like that of utero-gestation, one of 
continuous irritation. Of the meaning of this word irritation, 
every surgeon and every physician has in his mind quite enough 
reminiscences. Irritation, then, is the matter of consideration in all 
of these associative lesions; if happily, in such cases, we could 
exactly appreciate and exactly control such irritations, we should of 
course abort or resolve the results. 

It is not, however, by any means to be esteemed that all infantile 
diseases are influenced by, or indeed. even remotely associated with, 
dentition : mistakes of such nature are quite too frequently made, 
and infants are tortured, and in many cases have the existing dis- 

(in) ' 



112 ORAL DISEASES AND SURGERY. 

ease aggravated, by the lancing and cutting which follow. It is 
very true that irritation from this cause has not always an associ- 
ated external local manifestation; but such manifestation is, I think, 
much more frequently to be found present than absent, — at any rate, it 
should always have its full share in the diagnosis. It will of course be 
taken for granted that dental irritation is influenced to a most marked 
extent, all other things being equal, by the slowness or rapidity 
of the evolution of the teeth. Thus, such equality existing, we would 
not anticipate from the eruption of a single tooth the trouble of five 
or six, and such a difference in evolution is so common that it may be 
said of some children that they cut their teeth in mass, while with 
others it is a process of the greatest regularity and harmony. 
Again, the physical condition and age of the child are matters not 
without much significance. A delicate infant suffers more, as a 
general thing, than a robust one: while premature dentitions are at- 
tended with more danger than late ones. In taking into consideration 
the influences of this process, we are not to forget either the vary- 
ing degrees of susceptibility manifested in different individuals, as 
thus we are led to appreciate the fact that judgment is not to be 
founded alone on the extent or degree of local manifestation. Some 
children are preternaturally susceptible to stimuli, and these are 
not at all necessarily of the weak and feeble class; others, on the 
contrary, are so obtuse, even from earliest age, as to be very little 
influenced by any ordinary or common cause of irritation. 

To the experienced physician, the appreciation of associated or 
abstract dental irritation should not be a matter of difficulty. He 
sees and he does what is to be done, — what only can be done ; if the 
treatment fails, the fault resides not in the practice. In the first 
place, to understand dental irritation, one must be familiar with 
dental evolution ; this, of course, is the understanding of the physi- 
ology of the subject. We know the varying periods of eruption, 
and we are thus at once led very directly in our researches. If we 
find a source of offense, as manifested by a tumid, congested gum, 
we have only to pass a lancet down to the confined tooth, and, 
having done this, may expect and hope for relief from any general 
trouble which has been engendered by the just liberated organ. If 
we look into the mouth, and see no manifestations of offense, it is 
generally the case that dentition has nothing to do with a trouble 
which may have influenced the search, — not always, however, for it 
has been inferred that dentition may be a source of reflected trouble, 
while itself presenting no local signs. Still, such cases are very 



ASSOCIATIVE LESIONS OF FIBST DENTITION. 113 

rare, and when existing depend on great rapidity in evolution, either 
as a single tooth is concerned or the simultaneous advancement of 
a number. Many teeth, rapidly advancing at the same time, could 
very well be esteemed as a source of constitutional offense, not only 
as diverting in such direction an excess of the vital force, but also 
in local irritations induced in neighboring structures, and which 
might not at all be evident by any external signs. In these latter 
cases the physician can do nothing but increase, by indicated means, 
the ability of the system to endure the irritation ; such means being 
more frequently found in tonics than in sedatives. In the weak, 
strict attention is to be given to diet, to exercise, and to cleanliness. 
The character of the clothing is also of much consequence. If the 
milk of the mother is not properly nutritious, other means are to be 
taken to nourish the child. 

In cases where there seems simply an excess of irritability, such 
susceptibility is to be lowered by the withdrawal of everything ca- 
pable of fostering it ; this will pertain to the lodgment of the child, 
and to its food, drink, clothing, exercise, etc., matters which would 
at once strike the observant practitioner. 

Disturbance provoked in the alimentary canal, and fever induced 
through the process of teething, when existing conjointly with acute 
disease, of whatever character, necessarily aggravate such disease, 
and increase by just that much the attending discomfort or danger ; 
hence the recognized increased mortality in the exanthemata occur- 
ring at this period. 

The diseases, if they may be so called, directly associated with 
and dependent on abnormal dentition, and having, therefore, neces- 
sarily their cure more or less intimately associated with the correc- 
tion of the primary lesion, are— 

1. Localized Stomatitis. 

2. Irritative Fever. 

3. Diarrhoea. 

4. Spasms. 

5. Eruptions on the Skin, especially of the Scalp and Face. 

1. Localized Stomatitis. — The first indication in this condition, 
dependent on advancing tooth eruption, consists, most likely, in a 
sense of titillation or itching, — as, before any local sign is visible, 
the child is found disposed to rub the parts with anything coming 
into its hands, seeming most comfortable when biting upon hard 
substances. Slavering is also associated with this stage. After a 
time, tumefaction of the gums is observed, and this inflammatory 

8 



114 ORAL DISEASES AND SURGERY. 

action circumscribes or extends itself on the same principle as the 
vaccine areola, — that is, as influenced by constitutional or local cir- 
cumstances. If several teeth are attempting eruption at the same 
time, and these are situated at opposite sides of the cavity, then the 
probability is that the inflammation will be a diffused one. If, on 
the contrary, the irritation is confined to a single tooth, and there is 
in the habits of the child no particular inflammatory tendency, then 
it may reasonably be anticipated that the area of congestion will be 
very circumscribed. The shape and extent of face in the erupting 
tooth have not seemed to me to have as much to do with the amount 
of irritation as one would naturally infer to be the case. I have 
certainly seen quite as much trouble from an erupting incisor as in 
the case of a four-cusped molar. Bad and degenerating inflamma- 
tions are always associated with constitutional conditions. Thus, 
in scrofulous children it is sometimes the case that a semi-gangrenous 
ulceration is the result of cutting a tooth which it is quite troublesome 
enough to manage; while in children of a mercurio-syphilitic cachexia 
such a condition will be even aggravated, the gums and continuity 
of mucous membrane looking as if it was impossible to keep the 
parts from breaking down into general ulceration. When tume- 
faction of the gum is dependent on tooth eruption, and the child is 
of healthy condition, a certain evidence is found in the glistening 
character of the swelling: the part immediately over the tooth or 
teeth looks stretched and feverish. This tense look is nearly always 
present, and may, under all circumstances, be esteemed an indica- 
tion demanding the use of the lancet.* In unhealthy conditions 
this glistening is not commonly present, its absence being dependent 
on the flaccid, relaxed condition of the gum tissue. Here, as im- 
plied, the congestion is of more diffused character ; the part and 
associate parts are turgid and soft-looking. You esteem, in looking 
into the mouth, that scarification would be of service, but that it is 
demanded for a sense of general relief, rather than for a strictly acute 
local condition. Lancing in the first of these cases, if properly per- 
formed, yields an almost instantaneously good result ; in the second, 
such relief is gradual, and most likely inconsiderable. In the first, 
it is all-sufficient to the cure ; in the second, the constitutional indi- 
cations are soon felt to be of much more consequence than any local 
requirements. 

* The application of the tincture of belladonna to a gum thus congested is 
a source of much relief. A full saturation of the bromide of potassium is 
also an agent of more or less comfort. 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 115 

To lance the gums of a child, let the surgeon seat himself directly 
in front of the nurse, the height of the knees of the two parties cor- 
responding. Let the nurse now take the child on her lap, support- 
ing its whole body, excepting the shoulders and head, which are to 
rest upon the knees of the operator. In this position the nurse con- 
trols perfectly the legs and arms of the infant, while the surgeon has 
complete command of its head, and can examine and operate upon 
its mouth at his convenience. The face of the child should look 
toward the window, or, if night is the time of operation, the light of 
a candle or a lamp may be employed. 

A tooth should be lanced in consideration of its shape. Thus, if 
it be any of the anterior six teeth, either of the upper or lower jaw^ 
a single incision made sufficiently deep to feel the lancet strike upon 
the enamel is all that is required. This incision should be made 
across the mouth, or on the line of the cutting edge of these teeth. 
With the posterior teeth, the crucial form of incision is demanded: 
such form will alone relieve the advancing cusps, and afford the result 
desired. 

Concerning hemorrhage, it has not been my experience that any 
special danger is to be apprehended. I certainly never hesitated to 
lance the gums of a child on this score, and never met with a case 
that gave me any particular trouble. In ordinary cases, the loss of 
a little blood is rather to be desired than otherwise; while if a hemor- 
rhagic diathesis exists, the local application of strong alum-water or 
of bayberry-powder will generally be found all-sufficient for its con- 
trol. A little cobweb, as found in the cellar, wet with borax- water, 
and then dipped in bayberry-powder, will in ninety cases out of the 
hundred control the bleeding when laid over the incision, — the ap- 
plication to be secured by passing over it, if necessary, one layer of 
a delicate roller. 

A constitutional medicament, of good effect in these cases, will be 
found in the Erigeron Canadense, — one drop of the tincture to be 
given in a little water, each minute, until the bleeding ceases, or 
until twenty or thirty are taken. Opium and lead act very happily 
in combination. The dose of each must of course be small. A very 
good formula is as follows : 

R. — Pulveris opii, gr. £ ; 
Plumbi acetatis, gr. j ; 
Aquae rosaB, giij. 
Sig. Tablespoonful to be taken each half-hour, p. r. n. 



116 ORAL DISEASES AND SURGERY. 

Touching a bleeding gum with Monsel's solutions, or with nitrate 
of silver, is, in my experience, dangerous practice. The only alarm- 
ing cases of hemorrhage I have ever seen have been the results of 
these applications. It is true that such effects may rest rather with 
the operator than with the agents ; but it is seldom that one seems 
to succeed in using them with sufficient cleverness and localization. 
They are certainly much more apt to do a great deal of harm than 
any reliable good ; secondary hemorrhages are common to them, 
and, when ensuing, are always of a character much more difficult to 
manage than the primary trouble. 

Another matter in this connection particularly worthy of note, is 
the influence on the hemorrhage through the sucking propensity of 
infants. This is to be obviated by passing a roll of rubber or other 
convenient material across the mouth, and so confining it that, while 
it shall not fret the little patient, it will destroy the ability to make 
a vacuum. This manipulation is very simple and easy of accom- 
plishment. The ordinary soft india-rubber ring may be cut in the 
middle ; tie a piece of string or tape to each end, pass the rubber 
across the mouth, and fix the tapes on the back of the neck ; an hour 
or two will be found quite sufficient to retain the apparatus in the 
mouth. 

Cases of localized stomatitis, having association with the strumous, 
scorbutic, or syphilitic cachexia, require, as suggested, a treatment 
external to the cause exciting it ; the child must be built up ; the 
inflammation passing quickly into an adynamic type demands for its 
cure stimulation rather than depression ; or, to express the require- 
ments more justly and explicitly, a local treatment must be quieting 
and perhaps refrigerating, while tonics, combined with the mineral 
acids, will be required constitutionally. 

A child eight years of age, of marked scrofulous condition, tissues 
relaxed, abdomen pendent, was presented at one of my clinics, suf- 
fering with trouble in the oral cavity. Making an examination, the 
mucous membrane of the palatine aspect of the superior jaw was 
found angry and uncomfortable-looking, no tension at any point, but 
the whole membrane turgid, and yet flaccid-looking. In searching 
for the cause of trouble, the age of the patient directed a first atten- 
tion to the position of the first bicuspid teeth, the lateral incisors 
being erupted and in position ; exploration with the lancet — the 
deciduous molars had been removed long before — revealed these 
teeth on either side, with the second bicuspid of the right side nearly 
ready to erupt. The ordinary crucial incisions were then made. In 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 117 

the case of a healthy child, this would have been all-sufficient; with 
such a child, however, not so. Relief to some extent will cer- 
tainly be obtained from the incision ; but the congestion will con- 
tinue, and it may be will grow worse, the parts seeming to lack the 
energy necessary to the restoration. In this particular case, and 
which is here noted merely as a type, the mouth was ordered to be 
washed three times each day with very dilute brandy and aromatic 
sulphuric acid. Internally, lemonade was given every two hours, five 
drops of brandy being added to each wineglassful. Aromatic sul- 
phuric acid acts very happily in these and similar cases, or nitro- 
muriatic acid may be administered in from two- to five-drop doses, three 
or four times a day. Iron, combined with an acid, as in the Ferri 
Chloridi Tinctura. is a most admirable medicine, given in from five- 
to eight-drop doses, three times a day. It is found also not unfre- 
quently necessary in these cases to bring the acid, in a more concen- 
trated form, directly to bear upon some obstinate point of ulceration; 
this is done ve,ry readily by means of a pine stick. Dip the point 
into the acid used, and employ concentrated or dilute according to 
the seeming requirements of the case. The acid nitrate of mercury 
so applied is found sometimes to act very happily, or deliquesced 
chloride of zinc may be used. The zinc, followed by a brush of the 
officinal tincture of iodine, will sometimes induce granulation as if 
by magic ; or tincture of iodine combined with creasote may be 
employed with every hope of success. 

In syphilitic stomatitis, specific treatment must be conjoined with 
the supporting. A combination that I use with very satisfactory 
effect is as follows : 

R. — Hydrargyri chloridi corrosivi, gr. j ; 
Potassii iodidi, 5j ; 

Syrupi ferri pyrophosphatis, ^iv. M. 
Sig. From a quarter to half a teaspoonful, according to age, three 
times a day. 

It not unfrequently happens, however, that a treatment which 
may have preceded ours has been too free in the exhibition of the 
mercurials ; here this medicine is no longer to be used, but, con- 
joined with the supporting treatment, we are to employ the chlorate 
of potash: 



118 ORAL DISEASES AND SURGERY. 

R. — Potassse chloratis, iss ; 
Aquae, §viij. M. 
S. Teaspoonful, iDternally, four to six times a day, and the mouth 
to be washed with the same, ad libitum. 

An admirable local application in the syphilitic sore mouth and 
throat is made by adding to a six-ounce infusion of white oak bark 
two drachms of aromatic sulphuric acid and six grains of nitrate of 
silver. 

In all adynamic conditions of childhood, it is, I presume, a com- 
mon experience that no better treatment is to be found than lies in 
the observance of general hygienic laws. The food must be nour- 
ishing, and not given to repletion. Fresh air and exercise are 
necessities. The child should sleep by itself, or, what, as it is con- 
cerned, is even better, it might sleep with some young person of 
more robust and healthy condition. The daily use of the salt-sheet 
bath, with the water tepid or cold, according to the ability of the 
patient to bear, is an invaluable adjunct to restoration. Throw the 
wet sheet quickly about the person of the child, and rub until a 
fine glowing reaction sets in. In the use of this means, however, 
close attention is to be given to the daily result. If reaction is not 
secured, but the child grows cold, and the cutaneous capillaries con- 
tract unduly, then such bath is to be discontinued ; or if cold water 
has been used, it must be modified, even perhaps to absolute warm- 
ness. A good plan to adopt with this bath, is to commence with 
milk-warm water and advance by gradations to cold. 

All the functions of a child of scrofulous or syphilitic condition 
are to be carefully watched. If the bowels are habitually cos- 
tive, as is frequently the case, olive oil of good quality may be 
administered q. s. This oil not only obviates such a condition, 
but acts as a most desirable article of nutrition. If given alone, a 
teaspoonful or dessertspoonful, each day, administered at any con- 
venient period, will generally be found sufficient, — and, indeed, in 
many cases, too laxative. If the child is of an age to take the oil 
mixed with other food, much attention to the quantity employed 
will not be found of special consequence. In cases where the 
kidneys fail to eliminate with sufficient rapidity, small doses of 
sweet spirits of nitre may be exhibited. Buchu, where there is 
undue irritability of the urinary apparatus, will be found to apply 
very happily. A prescription which I very frequently make is as 
follows : 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 119 

Take of bnchu one ounce; add one and one-half pints of hot 
water, and simmer down to one pint; when cold, strain, and give in 
teaspoonful doses, four or six times a day, p. r. n. 

Particular attention to the state of the skin is also demanded. 
This tissue should feel soft, not relaxed ; moist, and reasonably oily; 
it must be kept very clean, but not washed too frequently with soap. 
Whisky or brandy, where stimulation seems indicated, may be added 
to the water with Avhich a child is bathed ; but a healthy skin is to 
be made rather from within outward, than from without inward — 
that is to say, a skin which does not properly perform its offices, in- 
dicates, as a general thing, some derangement ulterior to itself, so 
that the local attention implied is never to be esteemed but as adjunct 
treatment. It has not unfrequently happened to me to observe that 
a stomatitis having apparently a local signification has immediately 
disappeared on the correction of a trouble existing in the skin. 
This is markedly seen in the retrograde exanthems. 

Angina simplex, simple inflammation of the fauces, is not un- 
frequently dependent on irritations existing or having origin in the 
oral cavity. Here the trouble is one of continuity of structure, and its 
relief is found, of course, in the cure of the exciting trouble. Angina 
simplex, or the extension of the oral inflammation, is generally first 
made evident in difficulty of swallowing. Examination reveals the 
throat red and congested, the degree being influenced by the con- 
dition of the patient. Sometimes this congestion is so great as to 
make the act of deglutition an impossibility; even fluids taken into 
the throat will be ejected through the nostrils. The uvula oc- 
casionally will be enlarged to an extent, as the result of effusion into 
its cellular structure, which seriously endangers the respiration of 
the patient, compelling, indeed, in many cases, the amputation of 
the organ. In some instances degenerating aphthous patches (an- 
gina aphthosa) appear upon various parts of the mucous membrane ; 
these denote that the inflammation is adynamic in its type, and are, 
I think, always a matter of concern, just, indeed, as a phagedenic 
chancre is a cause for more alarm than a simple sore, implying 
a degenerative tendency and absence of vital force. An aphthous 
ulcer is a patch of varying signification. It is the form of ulceration 
and exudation so frequently seen in weakly, broken-down women. 
The microscope insists on the aphthous exudate as a fungous 
growth ; it has, however, as yet failed in designating an antidote. 
Angina simplex, it has been remarked, when dependent on any oral 



120 ORAL DISEASES AND SURGERY. 

trouble, may be expected to retire upon the removal of the immediate 
cause. This, however, is not always the case, as is witnessed in the 
adynamic types, or in children of very full or sanguine temperament. 
In these cases, a treatment must be pursued as implied in the indi- 
cations. If the continuance of such inflammation depends on a 
surcharged condition of the vessels, general or local depletion will 
be found demanded. Three or four Swedish leeches, or twice as 
many American, may be put upon the upper part of the throat; the 
number to be graduated to the strength of the patient and the 
urgency of the case. A treatment preliminary to this, and one 
which in my own practice I always employ, when the case is not 
especially urgent, consists in reducing the volume of blood, by 
the administration either of diaphoretics or the saline cathartics. 
Epsom salts, a teaspoonful in a wineglass of water, will carry 
much fluid from the blood of a young child ; or the spirits of Min- 
dererus — covering the patient warmly until diaphoresis is produced 
— given in teaspoonful doses, every ten minutes, will be found to 
sometimes very quickly break up such inflammations. Hot pedi- 
luvia are not to be neglected ; the feet and legs of the little patient, 
kept in hot water for the space of a quarter of an hour, w T ill, in very 
many cases, be all-sufficient for a cure. A less speedy but fre- 
quently very successful way of treating angina, consists in divert- 
ing, as it were, the seat of irritation ; thus, by the administration of 
nitre we may send it to the kidneys, or with tartar emetic throw it 
upon the skin. 

R. —Spiritus ammonias aromatici, 

Spiritus astheris nitrosi, aa §ss. M. 
S. Give from five drops to a teaspoonful, according to age, every 
three or four hours. 

The ammonia in the above prescription drives the congesting 
blood forward, while the nitre directs it toward the kidneys. 

An emetic will not unfrequently break up a sthenic sore throat. 
In the case of children, syrup of ipecacuanha answers every purpose. 
It may be given in doses varying from a half to a full teaspoonful, 
according to age, every ten or fifteen minutes, until the desired 
result of emesis is obtained. 

If, conjoined with the local inflammation, we have a sympathizing 
by the system at large, as manifested in fever, febrifuges are to be 
employed. The following combination will be found happily adapted 
to such indications : 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 121 

R. — Liquoris potassse citratis, §iij; 
Spiritus aetheris nitrosi, ^ss; 
Pulveris antimonii et potassae tartratis, 
Morphiae acetatis, aa gr. j. M. 

Of this mixture the dose for an adult would be a dessertspoonful 
every two hours ; for an infant one year of age, from five to eight 
drops might be given, being diminished or increased according to 
effect. Overdoses produce sick stomach. 

Diet. — This should of course be light, as in all sthenic inflamma- 
tions. The child may be limited to the breast alone ; or if age or 
circumstances will not permit of this, gum-water, or other light and 
unstimulating food, should be alone employed — that is to say, 
should be alone employed while the grade of the inflammation is 
running upward. Ice-cream is an admirable food, particularly when 
eaten slowly and continuously. By continuously, however, is not 
meant that great quantities are to be taken, but that a reasonable 
portion be made to last as long as possible. Eaten in this way, it 
is refrigerant not only to the inflamed part over which it necessarily 
passes, but to the system at large, lowering the heat of the whole 
body, and thus quieting the disturbed circulation. 

Chronic Angina. — Inflammation of the fauces, running into a 
chronic condition, in children, may perhaps always be considered as 
depending on some constitutional predisposition. In these cases 
the glandular bodies seem to be most markedly the seat of trouble. 
Granulations are generally prominent over the mucous membrane, 
this tissue being covered with a mucoid or muco-purulent secretion. 
Ulcers are very common, and not unfrequently are of such degener- 
ative tendency as to threaten the continuity of the parts. A dis- 
agreeable association, connected nearly always with a neglected 
angina, is the chronic enlargement of the tonsil glands. I have 
been compelled to operate in these cases, as every slight cold would 
so swell up these bodies as to render respiration almost as difficult 
as in asthma. I have just now under treatment a little girl, in 
whom, from this cause, these glands are so enlarged that respiration 
during sleep is accomplished only by an effort that it is absolutely 
painful to listen to. Of course the case is curable by excision or 
the cauterant; but to this neither parent nor child can be brought to 
submit. The sense of tickling and rawness in the throat, in chronic 
angina, is another source of discomfort; the patient is constantly 
kept coughing and hawking. This is induced not unfrequently 



122 ORAL DISEASES AND SURGERY. 

through the dryness of the membrane, and again as a result of the 
irritating nature of the secretions, or it may be dependent on ulcera- 
tion. From whatever cause arising, however, I have never found 
anything better adapted to its temporary relief than gum arabic or 
the jujube troches held in the mouth and allowed slowly to dissolve ; 
or a gargle compounded as follows may be used ad libitum : 

R. — Tincturse iodinii composite, gtt. xl ; 
Acidi carbolici, gtt. vj ; 
Glycerinse, 3j ; 
Aquae, ^vij. M. 

Brushing the part with the tincture of belladonna, or with a 
saturated solution of the bromide of potassium, is sometimes found 
to abort the severity in these cases very speedily. Difficulty in 
hearing is another frequent association of chronic angina, — the ex- 
planation being found in the inflammatory thickening of the Eusta- 
chian tube. Pain in the act of swallowing is the result of a lymph 
exudate in the submucous cellular tissue. This it is which gives the 
irregular thickening so observable about the posterior wall of the 
pharynx. 

Chronic angina, if not dependent on any specific constitutional 
conditions, would be most rationally treated by stimulation, local or 
general, or both, as would seem to be indicated. The ordinary 
domestic remedy of a red-pepper gargle, if judiciously used, not 
unfrequently produces a speedy cure. Unhappily, however, domes- 
tic medication is too apt to be carried to excess, and thus adds to, 
in place of subverting, a disease. If a true uncomplicated chronic 
angina presents in a child, — and it will not do to deny that such 
cases may exist, — let the patient first be treated with a lotion com- 
pounded as follows : 

R. — Tincturse capsici composite, ^ss ; 
Aquae, jjjviij. M. 

If a few applications of this gargle should not effect a change, let 
nitrate of silver be added, in proportion of one-half a grain to the 
ounce. If even this should not result in the desired change, then it 
will be well to esteem that a general medication is indicated. First 
we set about to correct any functional disturbances that may be 
present, and follow such corrections with tonics. Muriated tincture 
of iron is an admirable medicine, where the system seems to require 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 123 

building up; quinine, in the majority of cases, may be given in addi- 
tion, with a very happy effect. 

R. — Tincturse ferri chloridi, 3 n j ; 
Quiniae sulphatis, gr. x. M. 
S. To be taken in from three- to ten-drop doses, according to age, 
three times a day. 

Where treatment, as just indicated, shall fail, alterative medica- 
ments of the various classes may be tried, — alum-water, tincture 
of iodine, weak dilutions of creasote, acid nitrate of mercury, chloride 
of zinc, solutions of lead, etc. Constitutional vices must receive 
a full share of attention. I have presumed to imply that in children 
affected with chronic angina the cause is always found to exist in 
such direction. Scrofula is by far the most common of these vices. 
A scrofulous child is liable to almost any description of physical de- 
generation. Now, scrofulous degeneration is rather a difficult thing 
to describe, the conditions being so diversified and varied. A child 
descended from consumptive parents is degenerate, — it is not amiss 
to say scrofulous. A scrofulous child has not necessarily always a 
special distinctive type as in general signification is hereafter de- 
scribed. It may, for example, have white, delicate skin, tumid abdo- 
men, non-compact, pouting lip, and the languid, listless gait. It 
may have every belonging of the most marked lymphatic tempera- 
ment ; or, on the other hand, a scrofulous patient may look as if 
possessed of all the characters of a vigorous constitution. I do 
not know what better to do, in cases of this kind, than to make a 
general observation of antecedent and present conditions and 
found a treatment accordingly. Syphilis, it has been inferred by 
some writers, lies closely, or it may be in the distance, as the root 
of such conditions; but if this should be the case, a treatment anti- 
syphilitic is not necessarily implied. This peculiar vice may have 
lost itself in a general degenerative condition, just as an injury, 
which has of itself gotten well, may yet be the cause of broken 
health and physical adversity, — just, indeed, as phthisis may suc- 
ceed syphilis, long since inferred to have been cured. In all such 
"cases we can only hope, in the correction of ill conditions recognized 
as existing, to find the good we require. We may philosophize and 
reason, but if nothing functionally wrong is perceived, we must 
have recourse to a somewhat empirical treatment, building, as we 
say, the patient up. In other words, there are no specific means of 



124 ORAL DISEASES AND SURGERY. 

cure; therefore we resort to such general tonics as experience has 
demonstrated to be useful. Cod-liver oil, cream, mixture of sperma- 
ceti and milk, preparations of iron, infusions or tinctures of the bitter 
barks, as the Peruvian, serpentaria, gentian, etc., are medicines to 
be employed in these cases. 

2. Irritative Fever. — Irritative fever, fever from the irritation of 
teething, is a direction of infantile trouble very frequently demand- 
ing the attention of the physician. It may not be amiss, for the 
benefit of the student, to recall that by irritative fever we mean 
fever the result of something that produces overexcitement. This, 
it is true, would also be a definition of inflammatory fever, the two 
conditions being, as we understand, really one and the same, except 
in degree. Now, the irritative fever of dentition is, as a rule, a 
rapid fever — that is, it appears and disappears quickly ; the lancing 
of a gum causing it very frequently almost instantly to vanish : not 
always, however, for it can readily be understood that such a dis- 
turbance of the functional conditions could be excited as to make a 
return to an equilibrium much less probable than production of some 
organic change. 

All febrile conditions in children of a sthenic type are attended 
with much restlessness; but the fever of dentition is markedly so. 
Muscular excitability is a prominent association ; the sleep is broken ; 
thirst is very great; the appetite is impaired and irregular, the child 
taking the breast rather for the relief obtained from the moisture 
of the milk than from desire for food ; the pulse is not unfrequently 
driven to an incredible rapidity ; the face is flushed and burning ; 
the eyes are congested and protruded. Convulsions, and not unfre- 
quently death, mark the climax. 

The disturbance effected in the system, as has been remarked, 
will be found in proportion to the local irritation, and the age, con- 
stitution, and general condition of the patient. The marked mo- 
bility existing in the nervous structure of infants renders the brain 
peculiarly susceptible; it is therefore a most common association to 
find the feverish infant flighty, and perhaps entirely out of its head; 
while if febrile disturbance, consequent upon dentition, supervenes 
w T hen other diseases are in progress, such diseases will be commonly 
much intensified. 

The diagnosis of dental irritative fever is not always an easy 
matter, and simply because the fever is irritative, and not inva- 
riably inflammatory — that is to say, the local disturbance is con- 
fined to the vis vitse, and does not involve, to a perceptible extent, 






ASSOCIATIVE LESIONS OF FIRST DENTITION. 125 

the local vascular system. We look into the mouth, but see no 
swelling of the gums, no evidences of inflammation ; yet the trouble 
is there, and it may be that it is only by incision that the fever is 
to be controlled; the diagnosis must therefore necessarily not 
unfrequently be of a differential character. To aid us in this, 
we not only consider the absence of other causes of irritation, but 
we have a marked assistance in our knowledge of the varying 
periods of tooth eruption, and of the causes advancing or retarding 
such evolution. 

Where dental evolution is inferred to be the cause of a febrile 
manifestation, and incisions do not seem to be demanded, we are to 
resort to ordinary general treatment. Lemonade, prepared with 
crushed ice, is a most grateful and refrigerating febrifuge; the neu- 
tral mixture, made fresh, by simply adding the carbonate or bicar- 
bonate of potassa to lemon-juice, is another excellent medicine. This 
addition may be made to a full saturation. Or a refrigerating mix- 
ture, as follows, may be prescribed, and administered pro re nata in 
teaspoonful doses: 

B. — Liquoris potassse citratis, jfiij ; 
Potassii bromidi, 3j ; 
Aquae, gj. 

Much relief is commonly given by sponging the skin when it is 
very hot, using water and alcohol, or water and cologne, or water 
and vinegar. Bathing the wrists in cold water is another source of 
great comfort. Bromide of potassium alone is an admirable prepa- 
ration to administer in febrile conditions. To children it may be 
given, dissolved in strong, ice-cold lemonade, in doses of two grains 
or more to the tablespoonful. Tartar emetic, added to these doses 
in the proportion of the fortieth of a grain to each, assists its quiet- 
ing influence. Where the pulse is much excited, and the infant is of 
sthenic condition, tincture of veratrum viride may also be added, one 
drop to each dose ; in the use of this last agent, however, the effect 
as its action on the circulation is concerned is to be watched with 
care. Emetics are highly valued by some. Cathartics may also 
be used to good purpose, the sulphate or carbonate of magnesia 
being employed, as preferred. 

When, in defiance of treatment, a fever of irritation continues, our 
efforts are to be directed to effects that may be produced outside of 
the ordinary functional disturbances. The extension of inflammation 



126 ORAL DISEASES AND SURGERY. 

by continuity, where, for example, severe and unyielding inflamma- 
tion resulting from dentition exists, may produce pharyngitis, paro- 
titis, bronchitis, pneumonitis, gastritis, or it may excite to take on 
morbid action the brain, the heart, the liver, or, indeed, any organ 
of the body. When such sequelae occur, we are to treat the parts 
involved, as in any common inflammation, just, indeed, as we have 
been treating the unyielding fever, except that we may feel the 
necessity to make such treatment more vigorous; it maybe that 
under such circumstances we will find the local or general abstrac- 
tion of blood an absolute necessity. 

In these cases it is not to be forgotten, however, by the prac- 
titioner, that, conjoined with the original cause of inflammation, 
some other may exist; thus, a malarial influence may have been 
lying in abeyance, and needed but the depression, the result of the 
dental trouble, to allow of its asserting itself; or it may be that 
some half-corrected tendency to congestion is, by the excitation, 
entirely undone. Such associations are constantly to be considered 
if treatment is to be successful. This excitation of morbid action is 
well demonstrated in the association, with dentition, of diarrhoea 
and the cutaneous eruptions; while the treatment, wherever the 
secondary irritation shall exhibit itself, is recognized to have a 
common character. 

3. Diarrhoea. — The alimentary mucous membrane being con- 
tinuous from the mouth to the anus, it will be at once recognized 
that a localized inflammation could render irritable the whole tract. 
It is thus that diarrhoea, or, indeed, more commonly all the symp- 
toms of cholera infantum, associate with difficult tooth eruption, and 
it is thus that to cure a diarrhoea or an attack of cholera infantum 
we have so frequently only to cut down upon a certain confined 
tooth or teeth. I am led, however, to infer that it is quite too 
common a practice, during the period of dentition, to ascribe to this 
process not only every diarrhoea, but the numberless other functional 
irregularities which may happen to occur at such period. Diar- 
rhoea, or this combined with vomiting, has many causes apart from 
the influences of tooth eruption. 

The stomach of an infant may be likened to an enlarged portion 
of a common tube, and not only this, but it is. a vertical, or almost 
vertical, tube ; hence a child overfed needs only to be inverted to 
have the milk run from the orifice of the tube. 

Again, the mucous membrane of the intestines of an infant is 
tender and susceptible ; excess of food, or food not easy of digestion, 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 127 

irritates this membrane, and, by the relationship of tissue, excites to 
action the middle coat of the tube, yielding discharge or diarrhoea. 
Crapulous diarrhoea may thus be somewhat continuous, for the 
reason that, unassisted, the contractions may fail to relieve the canal 
of the source of offense, and thus their continued efforts keep up 
the continued discharges. Worms irritating the canal are the 
frequent cause of diarrhoea. In hot weather we generally have 
an increase in diarrhoea cases ; and not only is the irritation thus 
induced not limited to the intestinal tract proper, but the liver as 
markedly sympathizes ; hence the frequency in these months of 
cholera infantum, the excess of bile being thrown both ways. En- 
teritis, from follicular ulceration in typhoid conditions, may induce 
and keep up a diarrhoea in a child as it does in an adult. Tabes 
mesenterica is a cause of diarrhoea in the scrofulous infant. Syphilis 
may ulcerate and irritate the intestinal tract, just as we so frequently 
see such irritation in the mouth. These allusions are sufficient to 
remind us that diarrhoea is not a disease, but only a symptom, and 
that, whether occurring in the dentitional or any other period, it 
may have, as its provocative, a great variety of sources or lesions. 
When a diarrhoea depends on a dental origin it is perhaps always 
a condition of vascular perversion, and is entirely direct in its 
nature ; the erupting tooth or teeth inflame the mucous membrane 
of the mouth, and, by the continuity of tissue, the irritability ex- 
pends itself over the intestinal portion of the structure. It is well to 
remember that in diarrhoea of this character there is much or little 
mucin, according to the state of the inflammation, and much casting 
off of epithelial scales ; but there is, of course, nothing diagnostic 
in such phenomena, because of their not being peculiar to a par- 
ticular form or character of inflammation. We are to look at the 
mouth and at the throat ; if there is a local condition of irritation 
and inflammation, and if the vascular derangement extends as far 
as we can follow it, we have reasonable grounds for inferring that 
in the teeth resides the origin of the trouble, particularly if, having 
examined the system at large, we fail to discover other lesions. 
I do not desire, however, to be understood as asserting that it 
is only in this way we have dental diarrhoea, for I well know 
there is another way, and that is through the second of the legs 
of Bichat's tripod. I very well know that there is an influenced 
innervation, and that, if the bowels of an infant are weaker than 
its lungs or its brain, such deranged innervation will there expend 
itself. I have seen the diarrhoea of such deranged innervation 



128 ORAL DISEASES AND SURGERY. 

relieved almost instantly by an incision into a tooth-cyst, and yet 
there was no redness, no swelling, nor any other evidence of local ex- 
citability. These cases are, however, rare, and have their analogues 
in the reflex spinal irritations. The diagnosis must necessarily be 
somewhat differential in character; yet, where a case is at all ob- 
scure and the circumstances are urgent, it is commendable practice to 
make incisions over the positions of teeth whose periods of eruption 
correspond most nearly with the time of operation. 

It is very well, however, and indeed necessary, to remember that 
a mucous membrane may be inflamed, in varying localities, without 
having intermediate sanguineous disturbance. Thus a stomatitis 
and an enteritis might be present at the same moment ; the one de- 
pending on local dental disturbance, the other upon a cause or 
causes of entirely dissimilar nature. Now, in a case of this kind, 
having associative diarrhoea, it will plainly enough be seen that 
any treatment directed to the stomatitis would not (except as a 
similarity in practice might pertain to both troubles) affect the 
enteritis. To recognize these cases, antecedent conditions must be 
inquired into. Colds or atmospheric vicissitudes will, most fre- 
quently perhaps, be found an explanation of the disturbances. The 
cutaneous circulation, as a result of some injudicious exposure, has 
been depressed, and thus the enteritis has been forced upon a part 
having the least ability to resist the inrolling wave. In some in- 
fants, restless and nervous in their natures, a predisposition to enteric 
irritation seems to be inborn ; the slightest disturbance reacts in this 
way. It may not be that diarrhoea is the result, but the trouble 
exhibits itself in some evident way. 

The milk of a nurse is occasionally the source of a diarrhoea. 
Infusoria and crystalline substances will be found frequently, on 
examination, in such milk. Here a cure would be obtained only by 
a change from such diet to one which would be healthy or normal, 
— good cow's milk, diluted or pure, according to the age of the 
infant, being the best substitute. Other causes of diarrhoea, to be 
considered in connection with a supposed but doubtful dental source, 
are debility ; hepatic derangements, interfering with the venous 
circulation ; an increased peristaltic motion through mental emotions, 
as anger or fright ; a rheumatic or scrofulous diathesis ; malarial 
influence, etc. 

Diarrhoea from dental irritation, if inflammatory by the continuity 
of relationship in the membrane, generally demands the lancet alone 
for its cure ; the operator should free the advancing tooth or teeth. 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 129 

If, however, on the removal of such cause, the effect does not sub- 
side, the invoked and persistent irritability is to be treated on such 
principles as commend themselves. Sweet oil and paregoric, admin- 
istered internally, I have found to act very happily. To each tea- 
spoonful of the oil add from five to twenty drops of the opiate, 
according to the age of the little patient. Heating applications to 
the abdomen are very useful ; for example, a sinapism made as 
follows : 

Flour, ^ss; 

Mustard, 3j } 

Ginger, 5ij ; 

Black pepper, 3ss. 
Mix these together with a little vinegar, and retain against the 
skin until the part is well reddened. It is not at all necessary to 
blister the surface. 

Another and perhaps a more comfortable mode of treatment is to 
give small doses of Dover's powder, or, what I prefer, the liquor 
potassse citratis, in conjunction with minute doses of tartar emetic. 

R. — Spiritus aetheris nitrosi, ^ss ; 
Liquoris potassse citratis, ^ij ) 
Antimonii et potassse tartratis, gr. -J. M. 
Give in ten- to fifteen-drop doses each two hours. 
This combination serves to direct the irritability to the surface, 
and, by a relief thus afforded the affected part, not unfrequently 
yields a cure. 

If the inflammation has anything of a sluggish or passive char- 
acter, the spirit of Mindererus will act happily. Half-teaspoonful 
doses each two or three hours should be given. 

Diarrhoea from dental irritation, not inflammatory in character, is 
to be treated in consideration of its nervous relation ; and just here 
is the condition in which the bromide of potassium acts most satis- 
factorily. It may be given in five-grain doses, dissolved in water, 
or, if the practitioner does not like to commence in the infant with 
such a dose, he may try if less will answer his purpose, and increase 
pro re nata. Less than five grains, however, I do not think will do 
much good, unless, indeed, the child is very young. Spirit of Minde- 
rerus, sweet spirit of nitre, and the camphorated tincture of opium 
also act most satisfactorily in these cases. They may be given in 

9 



130 ORAL DISEASES AND SURGERY. 

such proportions as seem indicated. An ordinary prescription would 
be about as follows : 

R. — Spiritus Mindereri, gij ; 

Spiritus setheris nitrosi, ^ss; 
Tincturae opii camphoratas, 3ij. M. 
S. About twenty-five drops each two hours. 

The following combination is a valuable one, when other sources 
of irritation, not perhaps thoroughly appreciated, exist in conjunc- 
tion with the dental trouble : 

R. — Hydrargyri chloridi mitis, gr. ij; 
Pulveris opii, 

Pulveris ipecacuanha?, aa gr. j ; 
Magnesia? carbonatis, gr. xij. 
Divide into eight powders, and administer one after each opera- 
tion, if profuse ; otherwise, each two, three, or four hours, according 
to judgment. 

4. Spasms. — To appreciate the cause and condition of spasms and 
convulsions in early childhood, whether influenced or not by the 
excitements of dentition, one has but to consider the restless mo- 
bility of the cerebro-spinal system at such age. If, at an early 
period of life, we examine the gray matter of the spinal cord, we are 
struck with its development when compared with the similar sub- 
stance in the cerebral portion of the encephalic mass. To express 
ourselves differently, the ganglion of excito-motor or reflex action we 
find to be much in excess in its development, and not only so, but 
sensitive and susceptible, as its offices are concerned, to the last 
degree, — a result most likely of the necessity for the motion of growth 
and development existing in the members of a child ; such a system 
may be compared to a tensely-strung instrument, responding to the 
slightest touch. 

The difference between a regular and irregular motion is the dif- 
ference between an ability or disability of the cerebellar gray matter 
to perform its functions of co-ordination ; the difference between a 
co-ordinated and an irregular motion is the difference of spasm ; and 
if we carry it to the disability of the cerebral mass to influence, it is 
the difference of convulsion. 

Spasm, then, may be defined to be irritation, direct or indirect, of 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 131 

the spinal cord or of its terminal outshoots or nerves. This founda- 
tion-principle appreciated, the further consideration of the subject 
is not at all difficult. Very true it is, that there may be causes of 
disturbance that we cannot discover ; but the results, and the mean- 
ing of them, are not thereby rendered obscure : it would be only the 
cure that would be delayed or denied. 

We are prepared, then, to recognize in what way dental evolution 
is a cause of. spasm : it is precisely as it is a cause of diarrhoea, as it 
is a cause of fever ; but the reflected irritation in the latter case 
expends itself on the muscular system rather than upon the mucous 
or vascular. The cure, or the mode of cure, suggests itself: first, we 
are to remove the condition of irritation ; second, if the parts do not 
quickly soothe and quiet themselves, we are to help them. To meet 
the first indication we simply lance the gums. 1 do not think that 
in these cases we are to be influenced entirely by local manifesta- 
tions of congestion: we should cut freely down upon teeth whose 
periods of eruption suggest them as being the source of offense. 
Take a pledget of cotton, and, saturating it with a solution of 
atropise sulphas, thrust it, by means of some delicate instrument, 
into the cut you have made. This is quite equal, at least as 
such a case is concerned, to the more common subcutaneous 
injection, and tends to quiet the disturbed nerve filaments. Or 
the bromide of potassium, as before suggested, may be used ; or, 
drying the gum with a napkin, the smallest possible quantity of the 
extract of belladonna may be rubbed over the part, or it may be 
touched with a point of nitrate of silver. If yet the spasms should 
persist, some general effect on the nervous system at large must be 
secured. Tinctures of valerian and gentian in equal parts, given in 
ten-drop doses, repeated pro re nata, will sometimes act most satis- 
factorily. If this should not answer, the bromide of potassium, 
internally, may be employed. The bromide, cantharides, and cam- 
phor, as recommended by Dr. Chambers in epilepsy, constitute an 
admirable combination : 

R. — Potassii bromidi, gr. iij ; 

Tincturae cantharidis, gtt. iij ; 
Misturae camphoras, gtt. x. M. 
Sig. Repeat this in a little water, p. r. n. 

If, after proper trial of the above, — say a few hours, — the irrita- 
bility fails to be subdued, the inference will be that our diagnosis 



132 ORAL DISEASES AND SURGERY. 

has been a mistake, and that dentition has not been wholly, at least, 
in fault. 

At this point we see the necessity of glancing at other causes of 
irritation which may exist. Many children incline to nervous dis- 
turbance from anaemia ; this we know to be a quite common cause 
of such derangements. An anemic condition might not of itself, in 
a special case, induce spasm, but assisted by a conjunction with a 
second irritant, the two together could excite to the condition ; and 
one removed, the other could very well resist a curative agent, A 
glance here shows us why the sedative has not effected the cure; 
let us add iron to our prescription, and a very few more days will 
give a different result. Perhaps the condition of a child is just the 
reverse ; instead of being anemic, it is plethoric. Give to this child 
repeated doses of some suitable saline mixture, and conjoin with 
the bromide of potassium quarter-grain doses of calomel ; or, if you 
do not wish thus to medicate, diet closely for a few days, — give 
nothing but the breast, and this only in the daytime ; or, if the 
period is that of second dentition, deprive it of all but vegetable 
food, with water for drink ; a cure would most likely follow such 
treatment. Lack of good, fresh, pure air ; unwholesome food ; 
deficient or improper clothing; sleeping with debilitated persons; 
the milk of the nurse ; articles of food not easy of digestion ; hepatic 
derangements ; worms in the alimentary canal ; influences passed 
from mother to infant ; and numberless similar conditions, are ex- 
citing and predisposing causes of spasm and convulsions; and all 
demand, in every case, their share of consideration, if we are to be 
successful in treatment. 

Spasm resulting from the congestion of nerve centres, however 
induced, is not unfrequently tonic in its character ; the child may 
lose all consciousness ; it passes into the state that we call convul- 
sion. In these cases results must be obtained immediately ; we must 
relieve the overburdened part. How ? By derivation. Try first a 
hot foot-bath ; let it be as hot as the skin will bear. Inclose the 
steam of the water so that it shall envelop all of the child but its 
head ; compel it, if possible, to take teaspoonful doses of the spiritus 
Mindereri. The steam, or the steam and mixture in conjunction, 
will soon compel profuse perspiration, and thus secure a double 
derivation. Such treatment will, most likely, relieve the congested 
part; at least it has generally proved reliable in my hands. If it 
should not answer the intention, then a vein may be opened, or 
leeches may be applied. The opening of a vein in such cases I have 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 133 

never had occasion to resort to, but it is good practice, and is recom- 
mended by the best writers. The pediluvia and derivation by 
perspiration, I think, however, will be found reliable. If, after con- 
sciousness is restored, the pulse continues rapid, with fullness, give 
one-drop doses of the tincture of veratrum viride, or relax the sys- 
tem generally by doses of tincture of lobelia or the syrup of ipecacu- 
anha. Ten drops of either of these medicines, repeated as indicated, 
will very well answer the purpose. Keep the child now cool, and 
guard against every source of discomfort. 

An instructive and suggestive case where epilepsy had its irritant 
in dental irritation is described in the Medical Record by Dr. Na- 
thaniel Field. The paper states that a small boy, about five years 
of age, while apparently in good health, was suddenly attacked with 
an epileptic fit, from which he soon recovered. The parents were 
much surprised at the occurrence, and were unable to account for it. 
About two weeks afterward he had another strong convulsion, last- 
ing several minutes ; but it passed off without any constitutional 
disturbance. No cause for the attack was discovered by the relator 
or other practitioners. In a day or two the fits returned, and were 
repeated at short intervals for about ten days, during which time it 
is asserted that he must have had a thousand. Every resource in 
the power of Dr. Field was exhausted, and three eminent medical 
professors examined the child from the crown of his head to the soles 
of his feet, but no local irritation was discovered. After carefully 
watching the commencement of the paroxysms, he observed that the 
muscles of the left side of the face invariably began to twitch on the 
recurrence of a fit. After a convulsion had passed off, and while in 
a state of unconsciousness, he raised the upper lip, and found the 
corona of the second canine tooth, instead of having caused by a 
just relation the absorption of the root of the deciduous tooth, had 
passed behind it, and had forced it through the alveolus and gum 
into the lip. The gum was now slit vertically and the old tooth 
removed. In less than an hour the convulsions began to subside, 
and before the day was over they bad entirely gone, and never 
again appeared. 

Passive congestions are sometimes a cause of infantile spasms ; 
these are not difficult to distinguish from the acute or active con- 
ditions, the languor and sluggishness markedly contrasting with 
the turgidity and fullness. Again, they are distinguished from the 
active state in their results, these being not immediate, but medi- 
ate. Passive congestions depend on some obstruction in the circu- 



134 ORAL DISEASES AND SUBGERY. 

latory apparatus, and are, perhaps, more frequently associated with 
the chylopoietic than with any other system. Stagnations may also 
occur as a result of some interference with the respiratory office, or 
they may be the result of the action of some directly sedative poison. 
Wherever and however they exist, they are to be removed, if pos- 
sible, by meeting and combating the cause, which, of course, is the 
philosophy of cure. 

" In cases of pure irritation," writes Dr. Wood, "besides removing 
the cause, it is proper to diminish the nervous susceptibility and to 
control the cerebral irritation by diffusing the excitement over the 
whole system. To meet the first indication, narcotics may be em- 
ployed ; and none is more efficacious than opium, which, to diminish 
its stimulant influence, may be combined in some instances with 
ipecacuanha. Hyoscyamus, lactucarium, or conium may be substi- 
tuted, if on any account thought preferable. But before resorting 
to these remedies, the practitioner must be very sure of his grounds. 
He must be quite convinced that it is nervous irritation, and not 
active congestion of the brain, that he has to encounter. The second 
indication, above alluded to, is to be fulfilled by antispasmodics, 
administered by the mouth, the rectum, or the skin, and by the use 
of tonics, of which the metallics are deemed most efficient. Of these 
the oxide of zinc has perhaps enjoyed most reputation, though the 
chalybeates should be preferred in anemic cases. Should the 
digestion be impaired, and the system at large feeble, the simple 
bitters or quinia might be preferable to the metallic tonics. These 
remedies may often be combined in the same prescription. Thus, 
opium or hyoscyamus, assafetida, and either oxide of zinc, carbonate 
of iron, sulphate of quinia, or extract of gentian or quassia, may very 
properly go together. The cold or shower-bath, cautiously used, 
may also serve to strengthen the nervous system. Fresh air and 
nutritious diet of easy digestion are important. Any derangement 
in the hepatic secretions should be carefully observed, and treated 
with minute doses of calomel, blue pill, or mercury with chalk. 
When the disease depends on intestinal spasm, great advantage 
will often accrue from the use of laudanum, with assafetida or spirits 
of ammonia by the mouth, the injection of musk into the rectum, the 
application of a mustard cataplasm, or blister over the abdomen ; 
and if, as often happens, the bowels are distended with flatus, from 
the introduction of a catheter into the colon, and drawing off the air 
by means of a syringe. Should the disappearance of an eruption 
have preceded the convulsions, efforts should be made to restore it 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 135 

by friction with croton oil or other active irritant. In urgent cases 
a blister might be produced, by means of a strong solution of am- 
monia, on the surface previously affected. 

"In frequently recurring convulsions, resisting other measures, 
and threatening life, the practitioner would be justified in resorting 
to the inhalation of chloroform, which will often quickly quiet the 
spasms, and, if reapplied with each return, may obviate the danger 
until the tendency is past. It has the advantage, moreover, over 
other narcotics, of not congesting the cerebral centres, though the 
danger of fatal prostration from its use must not be forgotten.* 

"Even when asphyxia or apparent death may have resulted from 
the convulsions, hope should not be abandoned ; but efforts should 
be made by artificial respiration to restore the functions of the lungs, 
and consequently that of the heart." 

Finally, on this subject, I may direct attention to the connection 
between the troubles we are considering and the predispositions of 
an hereditary nature, so often found in association. When these 
deteriorative conditions exist, it is a necessity for success in treat- 
ment that we consider and combat them. 

5. Eruptions. — That the skin of childhood should be the subject 
of irritative changes is certainly only what is to be expected, and 
that variations in condition do most frequently occur is as true as 
that they are thus expected. 

Certain general considerations of the subject give us, I think, the 
key-note. Thus, in the beginning, a momentary thought directed 
to the great change which must result in the passage from intra- to 
extra-uterine life, would naturally lead to the anticipation of a cuta- 
neous hyperemic condition at once to be developed. In intra-uterine 
life we not only have the delicate and susceptible skin lubricated 
with the soft, bland smegma, but pressure on any and every part is 
jealously guarded against by the surrounding amniotic fluid. A 
single minute, frequently, and the most irritative changes occur : 
the waters pass away, the uterus crowds and presses upon every 
part of the child, while the outside world, still less considerate, 
receives it on its birth, its atmosphere stimulating and irritating, its 
rough points jagging and abrading, while unnecessary and too fre- 
quently ill-advised appliances and applications add to the common 
discomfort. 

Cutaneous hyperemia — erythema, as it is generally called — is a 

*It is found safer to combine with it a portion of sulphuric ether. 



136 ORAL DISEASES AND SURGERY. 

child's primary skin trouble. Such au erythema is certainly nothing 
more nor less than the variegated blush of an overstimulated circu- 
lation. Perhaps if the smegma were left undisturbed for a few 
hours, just as nature smeared it over the body, or until the skin had 
become somewhat accustomed to its new atmosphere, such hyper- 
emia would be avoided ; but as such excitability seems to do no 
immediate harm to the child, neither nurse nor mother, I imagine, 
would be found satisfied with such an arrangement. But does this 
hyperemia do no harm ? Does it not provoke an excitability in the 
skin which would be better absent ? Certainly children are most 
susceptible to cutaneous impressions, as witnessed not only in colds 
so easily taken, but by the variety of local manifestations, to the 
relief of which the practitioner is so frequently called. Dental irri- 
tations pertain to these troubles only as they act as excitants to the 
existing predisposition, or as they keep up an excitability which 
overmasters the corrective force natural to the vis vitse. 

Hyperemia running into an excess is inflammation. Inflammation 
of the skin finds a primary expression in the term Dermatitis. A 
dermatitis has secondary signification, as it presents peculiarities 
which lead us to look for reasons for such expressions. Thus, one 
inflammation in the skin is a simple sthenic increased vascularity, 
having the phenomena of redness, heat, pain, and swelling. A 
second is not regular and honest in its expressions, but throws out 
claw-like expansions, and looks dusky and threatening, throwing to 
the surface, here and there, blebs of serum. We distinguish this 
second from the first by the subterm erysipelas, or erysipelatous 
inflammation. Then we have an inflammation which presents the 
peculiarity of studding the face of the skin with pustules, and this 
derangement we distinguish by the term pustulae or pustular inflam- 
mation. Another form covers the inflamed surface with vesicles ; 
another throws out groups of nodules, — papular ; another circum- 
scribes its redness to patches, — rashes ; another presents raised or 
elevated patches, — urticaria, etc. All have alike the primary sig- 
nification of a perverted circulation, but differ in presenting dis- 
tinctive phenomena, these marking differences in local or constitu- 
tional circumstances. 

That dental irritation develops or creates the distinctive features 
in a skin disease is sheer nonsense. All that such irritation can 
have to do with the matter is that it exhausts the system, just as any 
pain exhausts and tires us, and reduces, as remarked, the ability of 
the vital force to guard or protect itself against an enemy or enemies 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 187 

in waiting at the threshold. It does not make the enemy, it only 
lets him in by weakening the bars. 

That a skin disease is thus introduced, and continued in an ability 
to resist applied medication, is true beyond the shadow of a doubt ; 
and it is for such a reason that the consideration of dental irritation, 
in connection with infantile skin diseases, is most important ; and 
yet this study, as the evolution of the teeth is concerned, differs in 
no wise from its study in relation to stomatitis, diarrhoea, or spasm, 
as certainly any intelligent mind must at once appreciate. It does 
differ, however, as far as a collateral treatment is concerned, and 
such treatment implies the study of skin diseases, as in works on 
Dermatology the subject is presented. It comes within our prov- 
ince here, however, simply to state some generalizations in such a 
direction, — an idea, if the reader pleases, as to the mode which such 
an investigation might be entered upon to compel it more readily to 
yield to us its secrets. 

A thousand complex scientific terms would scarcely exhaust the 
vocabulary of the dermatologist of the signification he has for the 
varieties and modifications of pathological skin phases. These 
diversified conditions, however, are found to revolve around eight 
centres. The centre of each is to be esteemed the nucleus or pith 
of the divisions ; the subdivisions are but radii of the common 
substance. 
All skin diseases belong to one of eight orders : 
1st. Pimples. 
2d. Scales. 
3d. Rashes. 
4th. Bullae. 
5th. Pustules. 
6th. Vesicles. 
7th. Tubercles. 
8th. Spots. 
1. Pimples — Papulae. — Small and pointed elevations of the cuticle, 
with an inflamed base — very seldom containing fluid, seldom sup- 
purating, and commonly resolving as scurf. 

Three primary divisions of papules are made: strophulus, lichen, 
and prurigo. 

Secondary divisions. — Strophulus intertinctus. 

S. albidus, S. confertus, S. volaticus, S. candidus. 
Lichen simplex, L. pilaris, L. circumscripta. 



138 ORAL DISEASES AND SURGERY. 






L. agrius, L. lividus, L. tropicus. 
Prurigo mitis, P. formicaus, P. senilis. 
P. pudendi muliebris. 

2. Scales — Scaly Diseases — Squamse. — Scales or laminae form 
upon the skin. Scales are of various forms, — in some cases, as in 
pityriasis, resembling a scurf; in other cases, as in ichthyosis, being 
broad and flattened, and bearing likeness to fish-scales. To mark 
the various prominent differences, four varieties are enumerated: 
Psoriasis, Lepra, Pityriasis, Ichthyosis. 

Subdivisions. — Lepra vulgaris, L. alphoides, L. nigricans. 
Psoriasis guttata, P. diffusa, P. gyrata. 
P. inveterata. 

Pityriasis capitis, P. rubra, P. versicolor, P. nigra. 
Ichthyosis simplex, I. cornea. 

3. Rashes — Exanthemata. — Irregular, variously figured patches, 
appearing on various parts of the body, leaving interstices of a 
natural color, and terminating in exfoliations of the cuticle. The 
designation is generally limited to efflorescences originating in fevers, 
as for example measles and scarlet fever. 

Bateman, however, includes, and perhaps more philosophically, 
Erythema, Urticaria, and Purpura in the division. 

The first division is, then, according to Bateman, Rubeola, Scarla- 
tina, Urticaria, Purpura, Erythema. 

Subdivisions. — Rubeola vulgaris, Scarlatina simplex. 

S. anginosa, S. maligna, Urticaria febrilis, U. evanida. 

U. persistans, U. conferta, U. subcutanea. 

U. tuberosa, Purpura simplex, P. haernorrhagica. 

P. urticans, P. senilis, P. contagiosa, Erythema laeve. 

E. papulatum, E. tuberculatum, E. nodosum. 

4. Bullse. — A condition in which effusion occurs on the true skin, 
separating the cuticle in the form of blebs or blisters. An effusion 
developed by a blister comes justly in its consideration under this 
head, for it is surely not less a bleb because a blister has pro- 
duced it. The difference between such a bleb and one resultant from 
an erysipelatous inflammation is that one has strictly a traumatic 
signification, while the second is a systemic offense. Blebs or bullae 
have three primary classifications: Erysipelas, Pemphigus, Pom- 
pholyx. 

The subdivisions are into Erysipelas phlegmonodes, E. cedema- 
todes, E. gangraenosum, E. erraticum, Pompholyx benignus, P. dinu- 
turus, P. solitarius. 



ASSOCIATIVE LESIONS OF FIRST DENTITION. 139 

5. Pustules — Pustulse. — An inflammation of the skin, resulting in 
the formation of purulent matter, which accommodates itself by 
throwing* up little circumscribed tumors. Whether one or many of 
these pustules rise on a common inflamed base depends on the 
fundamental or exciting cause; and because the conditions which 
produce pustular inflammation vary, so have we various names by 
which to distinguish and appreciate these causes. Five primary 
pustular inflammations exist : Impetigo, Porrigo, Ecthyma, Variola, 
Scabies. 

The subdivisions are numerous, depending on peculiarity of fea- 
tures. Impetigo figurata, I. sparsa, I. erysipelatodes, I. scabida, I. 
rodens, Porrigo larvalis, P. furfurans, P. lupinosa, P. scutulata, P. 
decalvans, P. favosa, Ecthyma vulgare, E. lurid um, E. cachecticum, 
Yariola, Scabies papuliformis, S. lymphatica, S. purulenta, S. 
cachectica. 

6. Vesiculas — Vesicles. — Vesicles differ from pustules in con- 
taining lymph — they look like little water pimples, although it is 
very frequently the case that the contained lymph is quite opaque: 
the end of a vesicle is by scurf or scab. There are seven primary 
varieties : Varicella, Vaccinia, Herpes, Rupia, Miliaria, Eczema, 
Aphtha. 

The subdivisions are Varicella lenticulus, V. conoidae, V. globate, 
Herpes phlyctsenodes, H. zoster, H. circinatus, H. labialis, H. prse- 
putialis, H. iris, Rupia simplex, R. prominens, R. escharotica, 
Eczema solare, E. impetiginodes, E. rubrum, Aphtha lactantium, A. 
adultorum, A. anginosa. 

7. Tubercula — Tubercles. — These are small, hard, circumscribed 
tumors — they may be fixed in a state of integrity, or they may be 
degenerative. There are eight kinds of these tumors — or, to express 
it differently, there are eight distinctive differences: Phyma, Ver- 
ruca, Molluscum, Vitiligo, Acne, Sycosis, Lupus, Elephantiasis, 
Frambcesia. 

Among these, subdivisions seem only necessary with acne and 
sycosis. Thus, there are three peculiarities in acne, which are 
marked by the terms Simplex, Indurata, Rosacea. In sycosis, 
Sycosis menti, and S. capillitii, designating the location of the 
tubercles. 

8. Macula — Spot — Mother-Mark — Freckles or Ephelis — Neevus. 

These eight classifications, after Bateman, with his subdivisions, 
make out of skin diseases all that concerns a present consideration 



140 ORAL DISEASES AND SURGERY. 

of them. It is for the student to comprehend the primary divisions, 
as their pathological differences are concerned ; the radii, or subdivi- 
sions, will be found to take care of themselves. Without an under- 
standing of the general subject one could scarcely expect to appre- 
ciate any accidental or positive dental relations. The subdivisions 
will be remarked, on examination, to be simply as family surnames 
distinguishing one child from another ; it is true, of course, that 
there are peculiarities of character, just as each child is peculiar, 
and by such peculiarities are these modifications on the primary 
condition named. Now, it is not by any means common to asso- 
ciate all these conditions with dental irritations ; yet it is certainly 
true that any one of them may have such association: therefore, if 
the student would understand one he must understand all. 



CHAPTER VII. 

ANOMALIES OF SECOND DENTITION AND THEIR SURGICAL RELATIONS. 

Understanding and appreciating the characteristics and relations 
of a normal dentition, we are prepared to pass to the consideration 
of abnormal or pathological conditions. Such conditions may be 
justly grouped under the head of anomalies. 

Anomalies in second dentition may be classed under seven heads: 

1st. Teeth common to the age, but erupting external or internal 
to the arch. 

2d. Teeth denied space in the arch, because of natural or surgical 
interference with the process of maxillary enlargement. 

3d. Germs developing in positions where their product must 
remain encysted. 

4th. The production of supernumerary teeth. 

5th. Third dentitions. 

6th. Teeth the periodontea of whose fangs are in association 
with the periosteum of the sinus maxillare. 

7th. Germs with heterogeneous development. 

These seven conditions, then, because they differ from a just or 
normal dental evolution, we call anomalies. 

Anomaly First.. — A tooth external or internal to the alveolar 
arch not unfrequently gives origin to an ulcer or locates epithelioma. 
Yet close as is this primary to the secondary lesion, and evident as 
such relationship would seem to be, I have known ulcers of the 
tongue, lips, and cheeks treated for months — of course, without suc- 
cess — where it has never seemed to strike the practitioner that the 
tooth could have any association with the disease ; indeed, in one 
case, where the patient was remotely connected to myself, death was 
the result of a cancer located in the cheek from this very anomaly. 
A second case, having a fatal termination, has occurred in my own 
practice, epithelioma of the cheek having been located through the 
irritating influence of a wisdom tooth out of position, and which 
seems to have been entirely overlooked. 

(141) 



142 ORAL DISEASES AND SURGERY. 

Note.-- -Even where there is excess of room, the permanent teeth 
not unfrequently erupt irregularly ; indeed, this applies so directly 
to the inferior incisors, that it may almost be said to be the rule 
rather than the exception. Unless, however, specially indicated, it 
is the best practice to leave them to nature ; they will almost always 
be found to come right of themselves. I would be understood as 
classing them with the anomalies only as derangement is marked 
and permanent. 

Anomaly Second. — Teeth denied space in the arch. This anomaly 
has perhaps the largest associative pathological connection. 

I have remarked that this lesion, if we may term it such, is more 
frequently the fault of the surgeon than of nature. If, for one mo- 
ment, we refer to the physiological relations existing between the 
first and second dentures, we may find that it is within our power 
to prevent the many ills that follow so frequently in this train, and 
simply by doing little, or, more commonly, nothing. 

The deciduous dental arch is filled, as we are all aware, com- 
pletely by its ten teeth. The second or permanent set is to com- 
prise in number sixteen, and each tooth certainly quite as large 
again as its predecessor. This increase in number and size of the 
teeth, it is evident, must be provided for in an enlargement of the 
alveolar arch. This provision is always attempted by nature in the 
process described by the physiologist as the elongatory. 

I will illustrate this process of maxillary enlargement by con- 
sidering the ten milk teeth as so many wedges placed in a springy 
arch. This arch it is designed to lengthen by additions to either 
end. If, now, these wedges should be removed before others were 
ready to take their place, it is evident that the elongation, being 
made at the ends, would, to a greater or less extent, be counter- 
balanced by the springing together of the parts at the sites of the 
removed wedges. The process of maxillary, or rather alveolar, 
absorption, is truly represented by this retraction of an arch. In 
proportion to the number of deciduous teeth removed prematurely, 
will be the curtailment in size of the arch, at least of its alveolar 
face. 

Let us, then, look at the results of such abridgment, — approximal 
caries of the teeth, periosteal troubles, trismus, odontocele, necrosis, 
the violent inflammations attendant on the development of the dentes 
sapientiae, etc. 

Note. — If there is a pathological Pandora's box, it is certainly the 
lesion of an overcrowded maxillary arch. 



ANOMALIES OF SECOND DENTITION. 143 

Such condition is made evident to the practitioner the moment 
he looks into the mouth of his patient: the teeth are jammed into 
the most uncomfortable-looking positions ; the deformity, however, 
mostly existing in the front of the mouth, — either the central in- 
cisors override, or the laterals are thrown back, or otherwise the 
cuspidati take the tusk position, standing out prominently from the 
arch, the bicuspidati occupying too anterior a location, approxi- 
mating, indeed, not unfrequently with the lateral incisors. 

Treatment. — To abort the ill consequences of such a contracted 
arch, extract at as early a period as possible the first bicuspidati of 
either side. This very simple operation will frequently not only 
secure against secondary lesions, but will occasionally correct the 
most annoying deformities. Let it be remembered, however, by the 
practitioner who prefers prophylactic to operative surgery, that on 
his treatment of the deciduous mouth depends, in a measure, the 
health and comfort of the adult. 

If I am asked what is to be done with the deciduous aching 
tooth, I may answer that it should have been filled on the first 
appearance of decay. This is a matter which no parent can afford 
ever to neglect. In the armamentum of the oral surgeon are plastic 
materials, easy and painless of introduction, which can be entirely 
depended on to perform the service required of them. 

Equal parts of chloroform and tincture of aconite, applied to an 
aching nerve on a delicate pellet of cotton, will sometimes 
instantaneously relieve this form of toothache. Another admir- 
able application is the atropise sulphas, dissolved in water, in 
the proportion of six grains to the ounce ; such a preparation, 
w r hile very effective, is to be used, however, with reasonable 
care. 

An exposed pulp in the deciduous tooth is, however, so constantly 
subject to irritation, that every indication calls for its destruction. 
The necessity is unfortunate, but the demands are persistent, and 
the removal of the part seems the lesser of two evils, between which 
the practitioner is compelled to choose. The application of arsenic, 
however, to such an exposed pulp has come to strike the experienced 
as questionable, and, as it is not a necessity, it will be found best 
perhaps to restrict the use of this agent to the permanent teeth. A 
deciduous pulp may be destroyed by touching it a few times w T ith a 
fully saturated tincture of iodine, or with either of the Monsel's solu- 
tions of iron. (See chapter on Odontalgia.) 

Arsenical applications are, however, frequently employed, but 



144 ORAL DISEASES AND SURGERY. 

unless a practitioner is very conversant with the physiological change 
that occurs in the fangs of these teeth, he had better not risk this 
means ; if, however, he feels prepared to employ such an escharotic, 
he can prepare no formula better than the following : 

B. — Acidi arseniosi, 

Morphiee acetatis, aa gr. x ; 
Creasoti, q. s. to make a thick paste. 

This is a paste quite universally employed for destroying the 
pulps of adult teeth. To apply it to the milk tooth, take a piece not 
larger than a pin's head, and, dropping it lightly into the cavity, 
cover loosely with cotton ; the part is washed out with warm water 
after four or five hours. I would not leave such a preparation in a 
deciduous tooth over five hours ; and if absorption of the fang had 
advanced to any extent, even one hour might be too long. Employ 
it fearlessly in the adult mouth, only remembering that you deal 
with arsenic ; but with the child too much caution cannot be 
exercised. 

The central incisors of the deciduous set of teeth should (a normal 
life continuing) last until the seventh year; the laterals until the 
eighth ; the first deciduous molar until the ninth year; the second 
until the tenth ; the deciduous cuspid until the eleventh ; and let it 
be remembered that the most posterior molar teeth that are in the 
mouth at the sixth year are the first permanent molars, and that 
these teeth get their place in the jaw without displacing any of the 
deciduous. 

For an account of some of these secondary lesions, together with 
treatment, see future pages. 

Anomaly Third. — This anomaly is remarked by examination of 
the classes of teeth erupted. Teeth all erupt in pafrs, so that one 
is not likely to be deceived. The anomaly is not unfrequently the 
result of interference with the development of the germ of the perma- 
nent through non-absorption of the root or roots of the deciduous 
teeth. 

Example. — A deciduous central incisor erupts — as the rule — 
about the seventh month, and is succeeded by the permanent at the 
seventh year. Now the physiological relation existing between the 
two teeth is as follows. At the time when the deciduous has attained 
its fullest development the germ of the permanent is at its apex. 
(See Fig. 52.) Retrograde metamorphosis now commences in the 



ANOMALIES OF SECOND DENTITION. 145 

fang of the deciduous, while, in an inverse ratio, the development 
of the permanent advances. It sometimes happens, however, that 
no process is set up for the taking away of these deciduous fangs, 
and, as a consequence, the permanent are compelled to make alveoli 
for themselves ; this they generally do by emerging posterior to the 
deciduous; but, as can readily be imagined, odontocele or encyst- 
ment is not unfrequently a result. 

Note. — Sometimes, long after the period at which the second 
dentition is usually completed, the incisors, as would seem to be 
natural, may be remarked, each occupying its respective alveolus. 
Yet here we may have odontocele. One of the incisors that we see 
is a milk tooth. This anomaly could, however, deceive only the 
very superficial observer, the difference in the classes of teeth being 
sufficiently marked. 

Because of this non-absorption of deciduous fangs, arrest in the 
development of the permanent sometimes occurs. It is really quite 
a nice point in practice to give advice in such cases ; if you direct 
the extraction, and no tooth comes to replace the one lost, you will 
be sure to get a good deal more censure than you could possibly 
deem yourself deserving. 

There are a number of conditions to take into the consideration 
of such a case, the most prominent of which is the existence or non- 
existence of the anomaly in a hereditary point of view. I am 
acquainted with a family where continued integrity on the part of 
certain front deciduous teeth, conjoined with the non-appearance of 
the permanent, has been a striking peculiarity as far back as the 
ancestors can be remembered. Ability to advise, in such cases, can 
only be gained by a careful study of the laws of dentition and idio- 
syncrasies. 

Surgical Relations. — In an examination of any obscure tumor of 
*the maxillary bones, examine the dental arch ; if a deciduous tooth 
occupy the place of a permanent, the existence of odontocele may be 
reasonably inferred. 

Anomaly Fourth. — Supernumerary Teeth. — These teeth differ 
from all others in being doubly fully conoidal ; this is the rule. It 
is, however, to be remembered that we meet with exceptions. Har- 
ris mentions having seen them so resembling the natural teeth as 
" to make it impossible to distinguish which should be called the 
supernumerary;" as for myself, I have never met with such decided 
exceptions. 

An encysted condition of these bodies obscures very much the 

10 



146 ORAL DISEASES AND SURGERY. 

recognition of their existence. In diagnosing diseases of the mouth, 
we must bear in mind that we have such odontoceles. The study 
of the evolution of such teeth is very interesting, but, of course, con- 
cerns the physiological rather than the surgical author. We may 
remark, however, that they do not seem to be necessarily a dermatic 
production, and the appearance of them in the mouth is as unac- 
countable as their association with ovarian and other remote tumors. 

Surgical Relations. — With the exception of the relation of super- 
numerary teeth to tumors, we have only to deal with them as they 
so strangely present themselves in the mouth. Let me give an 
example of such practice. A patient presents himself and tells you 
that there is a piece of bone working out through his mouth; and, 
truly, an examination will seem to verify his assertion. But there is 
one point which, if observed, will never mislead. Necrosis is always 
preceded by, and is associated with, .tumidity of the gum. The 
eruption of a supernumerary tooth is very gradual, and, so far as my 
experience goes, is never associated with inflammation. To extract 
such teeth, wait until they have emerged to the base of the cone ; 
or, if such waiting does not seem desirable, carefully force sharp- 
pointed forceps through the bone until you may be able to grasp this 
base, then with a rotary motion you may easily pull them away. 
Their alveoli need no attention. 

Anomaly Fifth. — Third Dentitions. — I would not be understood 
as referring here to that extra development sometimes occurring in 
young adult life, and yet the mention of the existence of such an 
anomaly is, perhaps, desirable. Thus, Columbus reports that one of 
his children had three sets of teeth. Valerius Maximus and Pliny 
relate similar facts. A son of Mithridates is said to have had two, 
and Hercules three. I myself have seldom seen this anomaly, and 
incline to think that its existence, in these modern times, is not co- 
extensive with the ancient period. I have certainly had quite five 
hundred persons tell me that such and such tooth or teeth were the 
third of the class, but examination, in almost every individual case, 
has satisfied me they were mistaken ; this anomaly has, however, 
surgically, little or no signification. 

Third dentitions, as here referred to, are those which are asso- 
ciated with advanced age. The student will recognize their phys- 
iology when I classify them with second sight, etc. The lesions 
of this anomaly are what might be termed associative — that is, 
we are occasionally so deceived by them as to be led falsely to in- 
terpret engorgements, congestions, etc. 



ANOMALIES OF SECOND DENTITION. 147 

A single case will illustrate the anomaly. An individual, aged 
sixty-five, applied to Dr. Chapin Harris, suffering with pain in the 
gums and jaws. No local lesion was at all discoverable. A tenta- 
tive treatment was resorted to. The apparent disease went on, 
however, entirely uninfluenced by the experimental medication, until 
at last it attained an intensity positively excruciating. In twenty- 
one days the mystery was explained by the eruption of a third set 
of teeth. The report of another case is, at the time of this writing, 
appearing on the pages of various journals describing a new and full 
dentition in the person of a gentleman eighty years of age. 

Anomaly Sixth. — Association of the odonto-periosteum with the 
membrane of the antrum of Highmore. 

It will be remembered that the easiest entrance to the maxillary 
sinus is through the palatine fang either of the second or the first 
molar tooth. It is, indeed, as I well know from experience, a very 
common thing to find the roots of these teeth perforating the cavity. 
Remembering this association of parts, it will be seen that many 
conditions, w T hich may have been deemed obscure, are thus made 
very plain. Dr. Harris, who seemed a close observer in diseases of 
the mouth, went so far as to say that two cases, mentioned by Bell 
and Bordenave, were the only authenticated exceptions where ab- 
scess had formed in this cavity at any other point than that at which 
it had been penetrated by the root of a tooth. 

A case mentioned in Braithwaite, from the practice of a Mr. Louis 
Oxley, of London, illustrates most happily the relations of this 
lesion. A young woman, of rather strumous habit, complained of 
a dull, aching pain under the orbit. The pain lasted from three to 
four months, attended by a gradual elevation of the orbital surface 
of the maxilla. The eye above this surface became at length so 
affected as entirely to lose its functions. At this stage of the 
case she was directed to use leeches and blisters behind the ears, 
and to employ drastic purges. After three months' blindness, the 
patient first perceived a discharge, from the right nasal fossa, of a 
thick, purulent fluid. This discharge had existed, he says, eighteen 
months, when he first saw the case. An examination of the mouth 
at once revealed the cause of so much misery, and the removal of 
three roots, in a state of periodontitis, was the simple means by 
which two most important organs regained their proper functions. 

The nasal opening of the maxillary sinus, it is known, is, in a 
healthy condition, almost closed by the duplicative of membrane 
lining the turbinated and neighboring bones ; congestion of this 



148 ORAL DISEASES AND SURGERY, 

membrane not unfrequently closes it entirely. Thus secretions ac- 
cumulate, giving alarming and threatening disfigurements to the 
face. The weakest points in the osseous boundaries of this cavity 
are, the floor of the orbit, the hard palate, the tuberosity of the 
bone, and the canine fossa. Any accumulation would necessarily 
be most apt to vent itself at one of these four points, unless atresia 
of the duplicated membrane alluded to should occur, and which is 
not commonly the case. 

Note. — My own experience regarding acute abscess of the antrum 
is, that in the great majority of cases the pus seeks to vent itself 
through the floor of the cavity. After the inflammatory action has 
passed to the suppurative stage, you will notice a swelling in the 
roof of the mouth at the side of the mesial line, corresponding to the 
diseased cavity: this is the abscess pointing, and, if left to itself, 
will be sure to make an ugly opening. Such a result will be found 
particularly undesirable if there should be any specific virus linger- 
ing in the system. But wherever this abscess should tend to point, 
it is of course desirable to abort it. 

If the assertion of Harris is true, concerning the almost invariable 
dental origin of this abscess (and certainly my own experience, 
so far as it goes, confirms him; for, while I have seen many cases 
of this kind, I have yet to meet with one where the treatment indi- 
cated was not primarily of a dento-surgical character), we turn 
naturally to the alveolar arch, seeking there the source of offense 
and defense. For a single moment, then, let me direct attention to 
a few dental lesions of the most practical character, and without the 
ability to recognize which, the practitioner will assuredly find him- 
self at sea. 

Because, when you turn to this dental arch, you find it entirely 
clear of teeth, and healthy-looking, you are not hastily to conclude 
that the primary lesion is not in such direction. You are to re- 
member that fangs of teeth are not unfrequently broken off in an 
attempted extraction, and that when so broken, particularly if very 
deep in the socket, the practitioner is not unapt to leave such pieces 
alone. Now, it is easy to understand that a fang so situated may be 
the source of extensive disease, and yet the gum over it be wjthout 
break in its continuity, and perfectly healthy-looking. The relation, 
in such a case, of the fang, is with the antrum, — it need necessarily 
have no external sinus. Make here an explorative incision along 
the gum down to the bone. If, happily, you come to a cavity, you 
will have hit on the origin of the trouble ; but if you find nothing, 



ANOMALIES OF SECOND DENTITION 149 

you have made only a simple incised wound, which left to itself will 
heal in a few hours. 

Again, because the part may have its usual complement of teeth, 
and each tooth should seem to be perfectly healthy, you are not to 
turn hastily away. There may be in one of these teeth a dead pulp. 
To satisfy yourself on this point, take up a delicate steel instrument, 
and strike with it each tooth separately, directing your patient to 
note any difference in the sensations; if he should start when you 
strike a particular tooth, my veracity for it, you have found the 
primary lesion. But still again, the lesion may be here, and yet 
the patient not express the anticipated pain. Take now a hand- 
mirror, and, placing your patient full in the sunlight, reflect the rays 
over the teeth, by placing the glass back of them. If in the arch is 
a dead tooth, you will remark an opacity in it not belonging to its 
neighbors : this is the offense ; extract it. 

If a tooth has a plug of metal in it, take the filling out: the 
cavity will, not unlikely, be found to communicate with the pulp 
chamber. 

If, now, we study periodontitis, the student will be prepared to 
make the most of the cases which we shall have to consider under 
various heads associated with such lesions. 

Periodontitis. — Periodontitis, peridentitis, pericementitis, dental 
periostitis, as the condition is variously designated, implies inflam- 
mation of the membrane associating the root of a tooth with its 
alveolus. 

Periodontitis, like inflammation in general, may exist either in 
the condition of activity or chronicity. 

The active form of the condition is most frequently found as the 
expression of direct local irritation; the chronic, as the result of 
systemic influences. 

Acute or active periodontitis, if not resolved or aborted, has a 
history which associates it with parulis. It commences commonly 
with a duli, heavy, gnawing pain in the parts affected : this is the 
signification of simple vascular excitement. As the grade of the 
inflammation advances, pain increases with it. The tooth seems to 
the touch of the patient to project beyond its fellows, and really does 
so. Occlusion of the jaws gives pain, which pain so grows in severity 
that the whole attention of the patient becomes directed to the 
avoidance of the contact. Finally, when not arrested, the action 
goes on to the suppurative condition, — the state of abscess ; and 



150 ORAL DISEASES AND SURGERY. 

this pus, discharging through a sinus which it creates for the con- 
venience, — generally opening upon the gums opposite the diseased 
point, — establishes the condition of parulis. 

Chronic periodontitis — subacute, as it might with as much pro- 
priety be termed — has a history markedly distinguishing it from the 
sthenic form : its causes are manifold. Mercurial ulitis is perhaps 
among the most frequent of the causes. Scorbutus is another very 
common cause, being abundantly expressed in every neighborhood 
where much pork is eaten to the exclusion of a mixed diet. From 
the exanthems many cases have origin : of such causes scarlatina 
seems the most provocative ; rubeola follows this in frequency. The 
phosphoric impression, as seen in connection with the workmen in 
match-factories, is a cause familiar to every surgeon. Neuralgic 
reflections certainly beget irritability in the peridental tissue, and 
which, in cacoplastic states of the blood, may degenerate the nutri- 
tional changes. Rheumatism and gout, as toxical conditions, are fre- 
quently found from clinical experimentation to be the irritants support- 
ing a resisting periodontitis. Uterine reflections, particularly from 
the menstrual relation, are other causes. Age is a common cause, — 
old people losing their teeth bv a degenerative condition of this 
membrane, which allows the organs to loosen and drop out ; or the 
same result is found frequently to coincide with tubular consolidation 
of the fangs, the excess of nutritional work thrown thus upon the 
periodonteum exhausting finally the excitability of this membrane. 
Accumulation of tartar, as it is called, is a common and frequent 
cause of chronic periodontitis. 

Chronic periodontitis — existing as a primary form — differs diag- 
nostically from the acute condition in the absence of the sthenic 
expressions. The tooth or teeth affected grow sore, tender, and 
elongated, but the progress is so slow as not to make the offense of 
sufficient import to the comfort of the patient to invite any vigorous 
antagonism, the expression commonly being that associated with 
the chronicity so frequently succeeding the acute form ; the parts 
are recognized to bfc in the state of disease, but the condition is suf- 
ficiently bearable to be endured. 

The acute and chronic forms of periodontitis find constantly a 
combined relation. Thus, the constitutional offenses are found 
capable of provoking the active condition, while local offenses, as 
instanced in salivary calculus, conjoin not unfrequently with the 
chronic state. 

Chronic periodontitis, except as associated with the acute form, is 



ANOMALIES OF SECOND DENTITION. 151 

not found to tend to parulis, but when degenerating to the forma- 
tion of pus, has the discharge about the neck of the diseased tooth 
or teeth. 

The importance and frequency of periodontitis rendering the con- 
dition one most necessary to be thoroughly understood, advantage 
may be taken of the present and succeeding chapters to direct atten- 
tion to the subject in the required detail. 

First and most commonly, it will be seen that the acute form of 
the condition we study depends on preliminary disease in the dental 
pulp, this organ being in a state of profound inflammation, affecting 
the perioclonteum by its continuity of relationship, or otherwise 
being dead, and proving the source of offense by its post-mortem 
changes and influences. In any and every case of acute periodon- 
titis which presents itself, whether exhibiting the very first expres- 
sion of a scarcely noticeable uneasiness, or the tooth being so 
elongated and tender as to render the slightest touch unbearable, 
attention is to be directed to the condition of the pulp cavity. If 
this, as is frequently the case, is found exposed, and the pulp dead 
or absent, then it is at once — no evidence of other vice, either consti- 
tutional or local, being seen — to be inferred that the trouble is that 
of an open, free inflammation, demanding for its relief common 
antiphlogistic medication. 

Where a pulp cavity is found closed, the tooth being undecayed, 
or otherwise having in it a tilling, a first indication directs an open- 
ing into the pulp chamber, no hesitation being necessary, as in per- 
haps all instances in which a tooth has become thus tender to the 
touch, the pulp, if not found actually dead, will be in such a state of 
congestion that its destruction has been insured. If, however, it 
is desired to attempt the abortion both of pulpitis and periodontitis, 
the plan suggested of uncovering the organ will be the wisest which 
may be pursued, as thus depletion could be practiced with the most 
immediate effect, and medication find direct application. Instances, 
however, present — and these are much the most numerous — where 
the periodontitis depends on a preliminary operation in which the 
pulp of a tooth has been purposely destroyed and removed, its place 
being occupied by metal as in what we are to study as a root-filling. 
Here it is not unlikely the trouble depends simply on the excess of 
work thrown upon the periodonteum from the abstraction of the pulp 
life ; or it may be .that the tooth is unable to endure the thermal 
changes resulting from the presence of the filling material ; or per- 
haps some particle of the pulp was not removed, which, disinte- 



152 ORAL DISEASES AND SURGERY. 

grating and decomposing* into its gaseous elements, has provoked the 
inflammation through pressure upon the parts about the foramen ; or, 
still again, it may be that a slight twist of the cotton or gold, or 
whatever may have been used to fill the root, has been forced 
through the foramen. The consideration of a condition of this nature 
calls always for the exercise of individual judgment aside from ordi- 
nary rules. If a pulp cavity has been well and scientifically treated, 
it would scarcely seem necessary or desirable to undo what had been 
done ; as having been properly done, with all collaterals considered, 
it is not to be esteemed that undoing and doing over could improve 
matters. We would therefore naturally consider the periodontitis 
as the lesion, and consider this alone. If, on the contrary, there is 
doubt of the operation, — if there is reason to infer that any portion 
of the pulp remains in the cavity, or that a twist of the filling has 
passed the foramen, — then a first indication lies in such direction. 

Accumulation of tartar provoking periodontitis would not be diffi- 
cult to distinguish, and the indication for its removal would be self- 
suggesting. 

False occlusion, another cause of periodontitis, calls alone for its 
appreciation to an observation which considers the common articu- 
lation. A tooth which, from any cause, strikes prematurely, is certain 
to succumb to the irritation if the offense be continued for any length 
of time. In such relation, the condition of newly-placed fillings is to 
be considered. A plug is never to afford the feeling of special contact. 
When a filled tooth becomes sensitive in its periodonteum, a very first 
attention is wisely directed to the contact ; should the metal be unduly 
prominent, it will, most likely, be at once noticed by an indentation 
seen upon its surface. Should this, however, not exist, the surface 
may be rubbed over with a little pulverized pumice-stone, so as to 
remove the general polish : the contact of the opposing tooth, if now 
it unduly touch, will distinguish itself by the polish it affords. 

Teeth unduly occluding from false articulation are to find remedy 
in the file, which is to cut away from the unaffected organs (or, if 
seemingly necessary, from the one which has expressed the irritation) 
such portion as shall remedy the defect. 

Still another cause of periodonteal inflammation, not unfrequently 
met with, results from accidents in the use of escharotics, which, 
having been applied to a cavity for the destruction of the dental 
pulp, have escaped and fallen around the neck of the tooth. A 
similar result has ensued from application of caustics to the gum for 
the arrestation of mucous oozing, or hemorrhage. Still again has 




ANOMALIES OF SECOND DENTITION. 153 

such inflammation been provoked by ligatures used with the rubber 
dam, or bv forgotten rings of rubber tubing or thread. In Fig. 53 
is exhibited such a ringed tooth, where the cause of a defying abscess 
was only discovered after extraction. The relation of ring and tooth 
is just as when removed from the mouth. 

Still another cause of periodontitis, but one happily apt to tend 
to rapid self-cure, is found in the process of wedging. -p TQ 53 
All teeth are made more or less sore through such mani- 
pulation, and the soreness expresses inflammation. Such 
wedging, however, employed in the mouths of old persons, 
or with those of bad constitution, may well result in the 
necessity for a medication, aside from the removal of the 
cause exciting the trouble. 

Taking it for granted that any and all existing sources of irrita- 
tion have been removed, an acute periodonteal inflammation, taken 
in time, may in nine out of twelve cases be aborted as follows. Pass 
a lancet several times through the gum down to the alveolus; let 
the patient hold water in the mouth, so as to prevent the formation 
of clot, and provoke free bleeding. As soon as the vessels and 
capillaries have disgorged themselves, paint the parts heavily with 
tincture of iodine, to which has been added one-fourth part of tincture 
of aconite, both being of the officinal strength. The philosophy of 
this treatment is sufficiently evident not to need explanation. 

A routine plan followed commonly with satisfactory results in 
incipient periodontitis is as follows : 

Place the feet of the patient in very hot water. Apply just in front 
of the ear a fly-blister of the size of a silver dime piece, and upon 
the nape of the neck a second, the size of a silver dollar. Admin- 
ister internally twenty-five grains of the bromide of potassium, 
having combined with it five drops of the tincture of veratrum viride, 
— this combination to be repeated in four hours, if relief be not 
sooner obtained. Lance the gums freely with a very sharp lancet, 
and afterwards keep cotton applied, saturated with the fluid extract 
of Hamamelis Yirginicus ; of which the best is the preparation known 
as Pond's, or this combined with equal parts of the phenol sodique. 
This treatment, if all local cause of offense has been removed, will 
seldom fail. It is found well to retain the feet in the hot water until 
the patient grows faint or breaks out into a perspiration. In the 
plethoric, in addition to the above course, half an ounce of the sul- 
phate of magnesia may be given in a goblet half filled with water. 

In the employment of the arterial sedatives in periodontitis, as in 



154 ORAL DISEASES AND SURGERY. 

an inflammation of any other part, regard is always to be had to the 
condition of the pulse, such medicaments being alone indicated in 
the sthenic conditions, and acting here with an efficiency and influence 
sometimes quite magical. Of such sedatives few seem possessed of 
the virtue of veratrum viride. I am well satisfied that it is in very 
many cases all that is needed in the treatment. Hydrate of chloral 
is another of this class of agents highly commending itself. That it, 
however, possesses sedative qualities dangerous in extent is scarcely 
to be doubted. To commence its exhibition in doses of not over ten 
grains is to err on the safe side. It is, however, on the bromide of 
potassium that every dependence is to be placed : it may be given in 
doses varying from ten grains to one drachm, or even one hundred 
grains, twenty grains being the ordinary dose ; this is to be pre- 
scribed in water, and may be repeated each two, four, or six hours, 
as seems indicated. 

As adjuncts, leeches are occasionally to be employed with great 
benefit. If the inflammation is associated with the lower maxilla, 
they may be applied below the jaw ; or, if objection be not made by 
the patieut, they may be used as in the upper jaw, being applied 
directly to the gum. 

A very simple plan of treating incipient periodontitis, and which 
will frequently be followed by immediate relief, consists in making 
a minute blister upon the gum overlying the affected root, through 
an application of a saturated solution of iodine. 

Lead-water and laudanum, as used so commonly in general surgical 
practice, is found a valuable refrigerant lotion to the inflamed parts, 
being applied on a pledget of cotton placed between the gum and 
cheek. A satisfactory combination will be found as follows : 

B. — Plumbi acetatis, 5j ; 
Tincturae opii, ^ss ; 
Aquae, ^x. M. 

To protect the inflamed tooth from contact with its neighbors, 
resort is to be had to a cap placed over adjoining organs. To this 
end, gutta percha is commonly employed, being easy and instantane- 
ous of application, requiring alone that a piece of the material about 
an inch square be softened in a flame and moulded over the parts, a 
mouthful of cold water hardening it into the required resistance. 
An instrument, however, more delicate, is found in a cap of silver, 
as devised by Dr. J. H. McQuillen. (See Fig. 54.) Such a cap is 
quickly made by the mechanical dentist, he requiring alone an 




ANOMALIES OF SECOND DENTITION 155 

impression of the tooth or teeth proposed to be capped, and which is 
secured in a moment by pressing over and around them a small lump 
of softened beeswax. 

An acute periodontitis resisting the various means here suggested, 
the attack increasing in severity, the surgeon finds himself compelled 
to abandon antiphlogistics, the indication being 
to advance the condition to the suppurative point Fig. 54. 

as quickly as possible. To this end, heating and 
exciting medicaments are required; warm water is 
to be held in the mouth, or a weak dilution of the 
tincture of capsicum may be employed ; about 
twenty-five drops to an ordinary-sized goblet of 
warm water will be found sufficiently stimulating. 
The domestic application of a roasted split fig to the gum increases 
the heat of the parts and invites suppuration to the surface to which 
it is used. Pursuing a natural course, the attack ends in the forma- 
tion of pus and the establishment, commonly, of open parulis. 

The appreciation and treatment of chronic abscess, whether 
founded on the acute form or arising as a primary condition, are to 
be found in a recognition of the indications of the associated condi- 
tions. These the reader will find considered with all fullness and 
clinical care in the chapters on "Alveolar Abscess," "Diseases of 
the Gums," "Necrosis," and "Odontalgia," to which he is referred. 

Anomaly Seventh. — Germs of Heterogeneous Development. — It 
occasionally happens that the dental germ, instead of arranging its 
parts according to the ordinary laws of its nature, assumes the 
most fantastic and heterogeneous shapes, giving such a variety of 
appearances that only a close attention may appreciate its dental 
character. Tumors of complex kinds are thus occasionally pro- 
duced, and, unless appreciated, are necessarily the source of much 
anxiety both to surgeon and patient. In an admirable memoir by 
M. Forget, crowned at the Academy of Sciences, Paris, in 1859, are 
illustrations of cases both of this seventh and the ordinary anomalies. 
I present them to my readers as being studies than which it would 
be time wasted to search for better. 



156 ORAL DISEASES AND SURGERY. 



PLATE I. 

Fig. 1. — b. Osseous tumor united to a molar tooth (a). 
Fig. 2. — a, b. Section of the tooth and of the tumor. 

Fig. 3. — a, b. Dental tumor formed by the anomalous development of the 
first two molars. 

a. Summit of the tumor, b. The root of the tumor. 

Fig. 4. — a. Cyst of the right branch of the inferior maxillary bone, the 
cavity of which is made visible by the circumferential resec- 
tion of its external wall. 

b. A molar tooth inclosed in the osseous tissue, and en relief upon 

the bottom of the cyst. 

c. External wall of the cyst, inverted. 

d. Condyle and neck of the jaw. 

e. Summit of the coronoid apophysis, with the insertion of the tem- 

poral muscle. 
Fig. 5. — Upper jaw of a horse ; view of half of the palatine face. 

a. Osseous cyst developed in the interior and right side of the jaw; 

it includes the tumor represented by Fig. 6. 

b. Right canine, thrust backward and inward toward the medio- 

palatine line. 

d. Alveolus of the left canine tooth. 

e. Osseous perforation, conducting to the interior of the cyst. 
Fig. 6. Intramaxillary osseous tumor (natural size) ; it was contained in 

the cyst represented in Fig. 5. 
Fig. 7 (300 diameters). — Represents a part of the section of the tumor shown 
in Fig. 6. This tumor appears to be formed entirely of the 
cement or osseous substance surrounding the dental root. It 
is an exostosis of the dental cement. This exhibits the struc- 
ture described in the explanation of Fig. 4, Plate I. 

a. Vascular canaliculi of the osseous substance of the tumor 

(Havers' glands). The tumor is traversed by these as in the 
normal osseous substance, — only they are more rare, more 
scattered, and more irregularly distributed. 

b. Osteoplasts disposed circularly, or nearly so, in a concentric 

manner around the Haversian canal, but less exact and evident 
than in the normal condition. 

c. The osseous substance, properly so called, in which the osteo- 

plasts, or characteristic cavities of the osseous tissue, are 
excavated. 




(157) 




(158) 



ANOMALIES OF SECOND DENTITION 159 



PLATE II. 

Fig. 1. Eepresents a cyst occupying the whole extent of the right half of 
the body of the lower jaw, and of the coronoid apophysis. 
The external wall of the cyst has been removed, and permits 
a view of the cavity, bounded by the internal wall b, which 
remains. 

a. The wisdom tooth, developed in an anomalous fashion in the 
base of the coronoid apophysis. 

c. Dental canal, open through the whole of its extent. It does not 
communicate with the cavity situated above it. 

Fig. 2.— d. Right side of the inferior jaw, affected by the rarefying osteite. 

a. Large molar tooth encysted in the bone. 

b. Interior of the cyst, with a black bottom, representing the mem- 

branous tissue that lined its surface. 

Fig. 3. — Same cyst, open at the side of the mouth. It reproduces (a and b) 
the aforesaid anatomical arrangements. 

Figs. 2 and 3. — c, c. Three incisor teeth, the canine tooth and the first two 
molars, removed from their position, and retroverted one upon 
another. 




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162 ORAL DISEASES AND SURGERY. 



PLATE III. 

ANOMALIES IN POSITION OE THE TEETH. 

Fig. 1. — a. Incisor tooth retroverted, and directed toward the intramaxil- 
lary symphysis. 

Fig. 2.—c. Canine tooth developed in the thick part of the floor of the nasal 
fossee, where it forms a prominence : the root is directed for- 
ward. 

b, b. Section of the maxillary sinus. 

d. Nasal spine. 

a, a. Posterior edge of the nasal fossae. 

Figs. 3 and 4. — Two other examples of anomalies in the position of the 
teeth. 




(163 




(164) 



ANOMALIES OF SECOND DENTITION. 165 



PLATE IV. 

Fig. 1. — a, a. Second grinding tooth of a horse, natural size, with considera- 
ble development of the roots, transformed into two spheroidal 
swellings. 
b, b. Portions of the maxillary bone sheathed in the tumor, and 
broken in its extraction. 
c. Orifice conducting- to the interior of an intradental cavity. 
d, d. Circular groove corresponding to the alveolar arch, and form- 
ing a sort of strangulation between the tuberosity a and the 
swelling e, which is underneath. 
/. Inferior surface of the crown of the tooth. 

Fig. 2. — Microscopic examination of the tumor (300 diameters). — Represents 
part of a thin section of the tumor shown in Fig. 1. The 
tumor was formed jointly by a hypertrophy of the dental 
ivory and a hypertrophy or exostosis of the cement, the greatest 
part being formed of the substance of the cement. 
a, b. Represents the ivory in its canaliculi — not ramified in this 
section — and terminating near the union of the ivory and 
enamel, 
c, d, e. Exhibits the mammillated arrangement seen in the cement 
at certain points of the surface of union with the ivory or 
dentine. This arrangement, often very elegant under the 
microscope, is also met with in the normal teeth. 
g, h. Osteoplasts, or characteristic cavities of the cement. They are 
especially remarkable for their size in all the preparations 
taken from this piece. 
/. Proper substance of the cement, or bone, in which the char- 
acteristic cavities are excavated. It is here, as always, homo- 
geneous; little transparent, except when it is reduced to very 
thin laminae. 



IPXjJ^TIE IV. 




166) 




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168 ORAL DISEASES AND SURGERY. 



PLATE V. 

• Fig. 1. — I ntram axillary bone bearing the two permanent incisors (a, a) 
superposed, and exhibiting an anomalous development. The 
alveoli of the same infantile teeth are partly destroyed ; this sec- 
tion formed the deposit. 

Fig. 2. — Tumor of the ramus of the inferior maxillary bone, affected with 
mollities ossium. At the surface are many openings of encysted 
abscesses; and the last molar, the crown of which extends slightly 
beyond the alveolar edges, and is developed in the thick part of 
the base of the coronoid apophysis. 

Fig. 3. — Section of the ramus, showing the numerous abscesses that exist 
throughout its whole extent. 




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CHAPTER VII L 



THE TEETH AND THEIR DISEASES. 



ALVEOLAE ABSCESS. 



Periodontitis, or inflammation of the alveolo-dental periosteum 
(considered in the previous chapter), when not successfully com- 
bated, has as its termination alveolo-dental abscess. To this con- 
dition, as a distinct one, attention may now be directed. , 

Alveolar or dental abscess has of course the history of an inflam- 
mation and suppuration anywhere in the body, having nothing 
peculiar to its history, except as such peculiarities associate with 
the anatomical characteristics and influences of the parts involved. 
It is a condition in which a tooth, diseased to the suppurative point 
in its enveloping membrane or periodonteum, is discharging, through 
some convenient orifice of exit, pus secreted by or formed in such 
membrane. 

The local features of alveolar abscess may be described in a very 
few words. At the apex or somewhere about the root of the affected 
tooth, a degenerative thickening of the mem- 
brane occurs, — the old pyogenic membrane, as 
it was termed. This, in its unhealthy condition, 
becomes shreddy and stringy, failing to organize 
the lymph constantly exuded or effused by it. 
The degeneration of this lymph is pus. As 
such membrane grows thicker and softer, and 
such pus accumulates, it becomes evident that 
space and vent are made necessities ; thus ab- 
sorption, through the pressure, is effected, and 
the matter, sooner or later, finds egress, giving 
generally that peculiar fistule in the gum, known 
as parulis or gum-boil ; the most vulnerable wall 
of the surrounding osseous parietes yielding first, thus giving the 
(170) 



Fig 




Sac of abscess as com- 
monly met with in dental 
parulis. 



THE TEETH AND THEIR DISEASES. 171 

direction and locating the fistule. The morbid process exhibited in 
an inflamed root-membrane consists in the accompaniment of the 
hyperemia by a hyperplastic state of the tissue-cells, these cells 
increasing not only in number but also in size. In this change it 
is that we find the explanation of the shreddy periodonteum seen 
more or less markedly upon all abscessed roots. 

A recognizable hyperemia is not, however, a necessity for the 
excessive proliferation of connective-tissue cells ; hence it is that 
epulic tumors frequently have origin in such hyperplasticity of the 
odonto-alveolar periosteum where expressions of vascular change 
have never been observed. 

The formation and confinement of pus in a cavity so obstinately 
closed as the alveolus of a tooth must necessarily inflict the severest 
suffering, and such pain is so constant an attendant of the condition, 
and is of such almost unbearable character, that any means calcu- 
lated to abort or limit its persistence is to be hailed as a boon. I 
take it for granted, judging from observation, that it is the severest 
form of odontalgia. The condition of acute pain, however, is con- 
fined to the period intervening between the accession of the acute 
inflammatory attack and the escape of the pus; the period, properly 
speaking, of periodontitis, — a period lasting from two days to ten : 
abscess fully formed, pain becomes limited to soreness. The treat- 
ment of the perfected alveolar abscess is very simple, at least as 
the indications are concerned ; consisting in the breaking up of the 
cyst and sac, and exciting an action of sufficiently healthy character 
to fill with granulations, of organizable force, the fistule. 

The appreciation of the cure of alveolar abscess begins of course 
with the treatment of the acute periodonteal trouble, of which it is 
seen to be simply a result. This was considered in the previous 
chapter, leaving here little to add, except that if such means as 
were recommended fail in securing resolution, more formidable, if 
thought desirable, are to be brought into requisition. 

As periodontitis is so frequently aborted by scarifying the gums 
freely and deeply, and, after the congested vessels have relieved 
themselves, constringing the parts by applications of strong tincture 
of iodine, so parulis can very frequently be anticipated by the fol- 
lowing trifling operation : 

With a sharp scalpel make a slight cut through the soft parts at 
the apex of the affected tooth ; next take up a spear-pointed drill 
and pierce through the outer plate of the bone into the cavity in 
which the sac is being developed, break up this sac, and, by means 



172 ORAL DISEASES AND SURGERY. 

of a delicate tent, keep the wound patulous for a few days. This 
little operation, I am well assured, through a pleasant experience, 
commonly spares the patient upon whom it is practiced days of the 
excruciating- torture which belongs to the formative stage of this 
disease. The philosophy of it will, I think, be at once recognized. 
Judgment is demanded, however, as to the time when such puncture 
is to be made ; it is to anticipate the moment at which pressure 
from accumulation commences. 

I cannot here help excepting to the common practice of ordering 
warm fomentations to the face in incipient abscess ; such practice is 
very objectionable, and not unfrequently results in scars which 
much deform the patient. If the practitioner should not desire 
to adopt the operative suggestion offered, let him order a roasted 
fig or raisin directly to the affected part ; either of these will do 
equally well the work of the poultice. Leeches, general blood-let- 
ting, vigorous antiphlogistic medication, any and every means that 
promises any good, should come between the periodontitis and the 
abscess. 

The anomalies of alveolar abscess, if such a term might be 
applied to conditions not at all infrequent, may perhaps be best 
studied through the medium of examples. I select a few from my 
own practice and that of others. If, happily, they may serve to 
throw light on any obscure case at present perplexing some young 
practitioner, I shall feel well repaid for the trouble of collecting 
them. 

A few years ago I saw, in consultation with a Dr. B. of this city, 

Mrs. , who had been afflicted with a running ulcer at the apex 

of the chin for four years. During this period the lady had been 
under the care of some five or six different practitioners, and had 
twice been operated upon for supposed disease of the bone. 

Suggesting that the origin and cause of this fistule might be found 
in some diseased tooth, I was assured that these organs had been 
most carefully examined, and that there was not an unhealthy tooth 
in the mouth. 

A superficial examination seemed to verify the truth of the 
assurance. Not satisfied, however, by such examination, with a 
steel instrument I commenced striking each tooth separately ; the 
patient thought that in the left inferior lateral incisor she experi- 
enced a sensation differing from that of the others. 

Placing her now in the full sunlight, I reflected the rays over 
the teeth by means of a hand-mirror; this test satisfied me that 



THE TEETH AND THEIR DISEASES. 173 

the incisor alluded to had lost its pulp, — it showed a slight 
opacity. 

I was now convinced that the disease was alveolar abscess, and 
predicated on the examination that an opening made into the 
affected tooth would discover the death of its pulp ; this was done, 
and the tooth found dead, as anticipated. The offending organ was 
extracted, some necessary local attention given the sinus, and the 
patient was well in a week. 

Comment on this case scarcely seems necessary; and yet it may 
not be amiss to suggest the explanation of the deceptively healthy 
appearance of the dead tooth. 

When the pulp of a tooth dies, discoloration of the enamel is the 
common result, this discoloration being caused by the absorption of 
the dead matter by the tnbuli of which the dentine is made up. 
Occasionally, however, the opacity is so slight as to be scarcely 
perceptible, and this depends on the dense character of the tooth, — 
not unfrequently the tubuli being so occluded as to destroy their 
capillarity : the dead pulp is not therefore taken up. A very vas- 
cular tooth, having a dead pulp in its cavity, will soon be turned 
almost black. A tooth in which the death of the pulp has been 
sudden discolors always more markedly than where it has been pre- 
ceded by a chronic inflammation, an explanation being found in the 
absence of that renewal of the process of calcification which in the 
chronic condition is apt to occlude the tubuli. 

A dead tooth, however, can always be distinguished by the tests 
given. 

The pathology of this case may be summed up very briefly. The 
death of the pulp provoked periodonteal difficulty. The inflammation, 
uncombated, resulted in alveolar abscess. The pus, after inducing 
by its presence the absorption of the bone, dissected its way under 
the soft parts down to the apex of the chin, where it discharged 
itself, — the abscess passed into the chronic stage ; the annoying and 
formidable fistulous ulcer was of course, because of its character, 
rendered incapable of being healed by any directly local treatment, 
or that not addressed to the true seat of trouble. 

In another consultation I saw a Miss B , a young lady, nine- 
teen years of age. In this patient, a fistule in the very centre of 
her hard palate had existed for some two years, giving rise to great 
uneasiness (as it had refused to yield to much treatment), a cancer- 
ous cachexia existing in the family. The denture in this mouth 
was also so complete as not to have attracted observation, every 



174 ORAL DISEASES AND SURGERY. 

tooth being perfect, with the exception of a single molar, which 
tooth had a small filling of gold on its grinding face. The filling in 
this tooth was removed, and the pulp found dead. Extraction was 
resorted to, and in three or four days all discharge had ceased. On 
the sixth day the patient was dismissed cured. 

It is not at all uncommon to find the sinus of an alveolar abscess 
venting itself somewhere on the cheek. This is too frequently the 
result of inviting the matter to the surface by the warm applications 
made to the side of the face. When pus thus seeks the surface it 
should be vented from the inside. While support to the parts 
toward which it is pointing is to be given by means of a compress 
saturated with a refrigerating styptic, alum- or lead-water being 
indicated, — anything answering the purpose which tends to con- 
tract or shrivel the skin, — a plain compress is never to be used, as 
this expedites the absorption which the indication is to abort. The 
puncture of such an abscess is a very simple matter, and will fre- 
quently be successful if the pus should have found its way even so 
far externally as to have but the skin between it and the atmosphere. 
Care must, however, be taken not to wound the facial artery or the 
duct of Steno. 

Abscesses, associated with the wisdom teeth, sometimes pass in 
the direction of the parotid region ; in these cases it is not uncom- 
mon to find the orifice of the fistule as low down as the clavicle, the 
unyielding character of the parotid fascia — a continuation, as it will 
be remembered, of the deep cervical — compelling this lengthened 
dissection. 

A form of alveolar abscess, which may lead to false diagnostic 
premises, exists in cases where, from the relation of a diseased 
fang with the maxillary sinus, the discharge empties itself into this 
cavity, to be in turn voided into the naris. (See Diseases of An- 
trum.) 

Another and indeed very curious result of alveolar abscess is the 
formation of osseous cysts on the side of the jaws ; the pus, instead 
of inducing the ordinary absorption, is provided for by the expan- 
sion of the outer plate of the bone. These cysts give little or no 
sense of fluctuation or crackling on pressure. There is no appear- 
ance of surrounding inflammation ; the soft parts covering them do 
not differ in any respect from the adjoining tissue. I have found 
such cysts or tumors generally associated with teeth in which the 
pulps have been destroyed and the fangs filled with metal. They 
form sometimes very rapidly, — that is, when compared with tumors, 






THE TEETH AND THEIR DISEASES. 175 

for which they may be mistaken. I have treated them where the 
cyst has enlarged to the size of a half hickory-nut in a few months. 
This rapid growth is particularly diagnostic. The easiest treatment 
of such cysts would be of course the extraction of the offending 
tooth ; but they are also to be cured by opening them transversely 
and stuffing the cavity with lint saturated with tincture of iodine, 
or some other stimulant ; the cyst is thus obliterated, and the sac at 
the end of the fang destroyed, through the healthy reaction which 
the treatment excites. These cysts are not to be confounded with 
the sub-periosteal exudates frequently found overlying the site of 
diseased roots. 

Mr. Smith, in illustrating a lecture on alveolar abscess, notices 
the following cases from his practice: 

A few years ago, he says, a middle-aged man asked his opinion about 
a fistulous sore which opened on the middle of his whisker of the right 
cheek. Mr. S. introduced a probe, and finding that it came in contact 
with the fang of the last molar tooth of the upper jaw, persuaded 
the patient to allow him to extract it, on the promise that he should 
be well in a few days. On the tenth day the gentleman wrote, by 
post, to say that the discharge ceased the day the tooth was extracted, 
and that at the time of writing it was perfectly well. 

He relates the case of a young woman who came under his charge 
at the infirmary, with a fistulous sore in the fore part of the throat, 
within an inch of the sternum. It had been discharging upwards of 
a year. On probing it, the instrument could be passed in the direc- 
tion of the molar of the lower jaw on the left side. On inquiry, the 
patient said that eighteen months before she had a tooth drawn, 
but the fangs had been left in the jaw. Afterward an abscess 
formed, which descended lower and lower until it burst midway 
between the sternum and pomum Adami. Mr. S. extracted the 
stump, it still discharged for a week, when it got well without other 
treatment. 

Mr. S. alludes also to a case where a horse had been condemned 
to the knacker's yard, as being afflicted with the glanders, having a 
foul, offensive discharge of purulent matter from the nostrils, and 
being in the last stage of emaciation. A veterinary surgeon, finding 
that it could not masticate its food, examined its mouth, and detect- 
ing a carious tooth in the upper jaw, extracted it. The discharge 
ceased ; the horse soon began to thrive, and got well. 

Mr. Fleischman (British Medical Journal) relates the following 
example: "Miss Rose S., a little girl, aged five years, had been 



176 ORAL DISEASES AND SURGERY. 

troubled about three months with a constant, though not profuse, 
discharge of slightly-purulent mucus from the right nostril ; it ap- 
peared to be the sequel of a cold. The mucous membrane, so far as 
it could be examined, was healthy, and there were no indications of 
any morbid growth. She was ordered a strong injection of gallic acid, 
and took, concurrently, small doses of the sesquichloride of iron. The 
only advantage she derived was that the discharge lost its purulent 
character ; in amount it remained about the same, though the treat- 
ment was long persevered in and other local astringents tried. I 
suspected," says Mr. F., "there must be some undiscovered local 
irritation. Not being able, on careful examination, to find anything 
wrong in the nasal passages, I looked to the condition of the teeth, 
and finding the right upper canine carious, removed it. The dis- 
charge was much lessened on the next day, and in the course of a 
day or two disappeared altogether." 

Mr. Fleischman, although he does not seem to see that his case is 
simply one of alveolar abscess, but offers it as "a good illustration 
of reflected irritation," truly remarks that it "teaches us that the 
fons et origo mali is not always just where we might expect to 
find it." 

I have had, in my own practice, several cases where the pus of 
an alveolar abscess discharged itself from the nares; but the dis- 
ease, in every case in which I have seen it, where the sinus passed 
in such direction, was associated with the central incisor teeth. It 
is, however, to be inferred that other of the teeth might associate 
sinuses with the posterior aspect of the nares. dripping their dis- 
charge behind the veil of the soft palate, a number of such cases 
being indeed on record. 

Abscesses of this nature are not unfrequently associated with the 
eruption of the wisdom teeth. The arch being too small to accom- 
modate the advancing organ, it becomes, as a matter of necessity, an 
agent of irritation ; inflammations of the most severe nature are thus 
oftentimes provoked, inducing, too commonly, trismus and abscess. 
(See Trismus Pentium.) Abscesses from this cause generally dis- 
charge about the neck of the tooth; they mey, however, void them- 
selves in other situations, as, for example, upon the face or neck. A 
case illustrative comes this moment to my mind: — Dr. D., a medical 
gentleman, suffered for some time with heavy, dull pain in the right 
half of his lower jaw, and which was attributed to two of his teeth, 
much decayed, but which, however, had been treated and plugged. 
Inflammation of a severe character finally developed, and, in defiance 



THE TEETH AND THEIR DISEASES. 177 

of all treatment, ran on to abscess, which abscess discharged upon 
the cheek. The pus voided, relief, of course, was obtained. The 
sinus, however, continued to discharge, and, at the time of my being 
consulted, the ulcer had become a source of much annoyance as well 
as deformity. This case had been examined by various friends of 
the gentleman, and, while all pronounced it alveolar abscess, all 
associated it with the treated teeth. The removal of a developing 
wisdom tooth, a single cusp alone of which presented, caused the 
fistule to heal in a single week. A complication sometimes met 
with in abscess discharging upon the cheek, and of which it is most 
important that note should be taken, consists in a relation of the 
sinus with the duct of Steno. I have in the past few years met 
with a number of cases of this nature, and by the operation required 
for salivary fistula have been enabled readily to cure them after the 
failure of every device not entertaining an appreciation of such condi- 
tion. It is to be impressed that such fistulse deceive in the very 
limited salivary discharge, this fluid being easily overlooked in its 
relation with the pus ; my experience would lead me to infer that the 
opening into the duct may not unfrequently be of the most diminu- 
tive calibre. Where such a case is recent, it is proper to attempt a 
cure through the granulative process, trusting by such means to cover 
in the break of the duct ; to accomplish this, no better means may be 
employed than daily touching the parts with tincture of iodine or 
with crystals of the chloride of zinc, it being of course understood 
that the dental relation of the disease has been previously cured. 
If such means fail, and this will be found the most likely, then an 
operation is required. (See Salivary Fistule.) 

Alveolar abscess also not unfrequently exists where the discharge 
is exclusively through the foramen of the tooth, this orifice being 
enlarged. The gums in these cases may be unaffected, affording no 
signs of disease, the evidence of the discharge being perhaps alone 
in a peculiarly disagreeable taste experienced by the patient. To 
cure these cases, it may be sufficient to throw the required injec- 
tion through the canal of the tooth ; but, should this fail, the method 
of entering the cyst through the alveolus is to be tried. To so 
enter such a cyst, a very delicate trephine may be employed, or, 
what commonly answers every purpose, a spear-shaped drill may be 
used. Incising the gum over the apex, the drill is simply to be 
rotated into the cyst; precaution, however, is to be taken that none 
of the bony particles be allowed to remain, adding their quota of 
offense. This is guarded against by the free use of the syringe. 

12 



178 ORAL DISEASES AND SURGERY. 

An alveolar discharge, which may be termed false abscess, is met 
with frequently in association with alveoli into which salivary cal- 
culus is intruding. In these cases no difficulty is to be experienced 
in the diagnosis; the discharge is seen about the necks of the 
affected teeth, the gum is more or less puffy, and the irritating de- 
posit is evident enough. To cure cases of this kind, it is commonly 
necessary only to scale or cut away the offending agent, and, after 
making a few incisions through the congested and debased gum, 
stimulate the parts by such applications as may seem indicated. 
Few medicaments are more reliable in this direction than the dilute 
aromatic sulphuric acid, or this combined in equal proportions with 
the tincture of capsicum. It is found, however, not unfrequently 
the case that the deposit has so destroyed the sockets of the teeth 
that no cure is possible outside of extraction. (See Salivary Cal- 
culus.) 

Chronic alveolar abscess, resisting local treatment, is to be viewed 
commonly as of constitutional association. In persons who are 
laboring under the effects of a mercurial poisoning, the cases are 
found most resistive ; indeed, in many instances, it is felt to be use- 
less to make any attempt to save the affected teeth, the organs being 
absolutely thrust from their sockets and falling into the mouth. 
Where not too loose, however, the gums are to be incised every few 
days in the vertical direction, and attempts made to resolve the 
turgiclity and puffiness by paintings of the tincture of iodine and 
capsicum, alternated with washes of chlorate of potash and cologne. 

B. — Potassas chloratis, ^ss; 
Aquas Colon., gj ; 
Aquse, §vij. M. 

Sig. Use many times daily. 

Internally the chlorate of potash may be directed in doses of 
fifteen grains, repeated three times daily. 

R. — Potassse chloratis, 3iij ; 
Aquae, §viij. M. 

Sig. Tablespoonful as a dose. 

The rheumatic diathesis is to be recognized as at least a predis- 
posing cause to alveolar abscess, and one which at times forces 
itself upon attention in treatment of the condition. As this toxical 



THE TEETH AND THEIR DISEASES. 179 

influence is recognized as having affinity with periosteal tissue, so 
there is no reason to doubt that occasionally it is the resistive agent 
in the cure of such conditions. A similar view will also be found 
to hold good of the malarial poisons, and, indeed, it very well may 
be, of all the other toxical conditions. Not at all that it is to be 
affirmed that such poisons have necessarily, in all instances, a direct 
relation, but that, being depressent to the system at large, they 
antagonize that reparative influence, without which the parts may 
not restore themselves ; precisely, if an illustration be needed, as 
a venereal ulcer, however proper and vigorous the local treatment, 
refuses to be made well until systemic influences are considered and 
antagonized. 

Gout is another constitutional predisposition to chronicity in 
alveolar abscess, just as it is a frequent excitant to pulpitis ; and an 
abscess which refuses to respond to any direct medication yields, 
with such predisposition, to a few doses of colchicum. Defying 
abscesses of this nature are oftentimes found to give way to the 
alterative influence of a week at the seashore, or a trip to the 
mountains. 

In chronic abscess the discharge must necessarily continue so long 
as the periodonteum remains in its pathological state. It is there- 
fore always necessary in association with any systemic treatment 
which it may be desirable to adopt, to break up the local condition. 
To accomplish this, no better means can be employed than to tear 
the sac to pieces by means of a delicate, soft excavator passed 
through the sinus. After such breaking up of the sac, the part is to 
be syringed daily with an aqueous or vinous dilution of the ordi- 
nary officinal tincture of iodine, — about half and half of either being 
a good proportion. Another most excellent agent is found in the 
chloride of zinc. Of this salt, a solution of three grains to the 
ounce of water may be employed, a tent of cotton being saturated 
and carried into the cyst, or, charging with a few drops the ordinary 
hypodermic syringe, the fluid may be thrown into the sinus. Other 
local medicaments are found in nitrate of silver, sulphate of copper, 
tincture of capsicum, permanganate of potash, in the passage of the 
electro-galvanic current, in carbolic acid, in creasote, in alcohol, et 
hoc genus omne. 

Where an abscess discharges itself exclusively through the pulp 
canal, the very best plan of treatment is to make a counter-opening 
in the gum and proceed as directed for the abortion of the acute state 
of the disease, using, besides, injections and tents until all discharge 



180 ORAL DISEASES AND SURGERY. 

ceases; or, if objection exists to this, it will sometimes be found to 
answer to carry into the canal threads of silk saturated with the 
medicament selected. Another and a better mode than the use of 
the threads is, however, to introduce into the canal a plug of gutta 
percha, in which a hole is to be made of a size just sufficient to re- 
ceive the nozzle of a delicate syringe. Thus directed and controlled, 
injections may be forced through the foramen. Any treatment, 
however, except that by the counter-opening, will seldom be found 
satisfactory. 

A tooth having such discharge through its canal, and thus inca- 
pable of bearing a filling, may have such filling retained without 
response by making the counter-outlet through the alveolar wall. 
Such a treatment I have frequently adopted with much satisfaction, 
having success in saving the tooth where, without the puncture 
made through the gum and bone, the cavity would not have endured 
the plug for half an hour. 

An explanation of chronic alveolar abscess where no medication 
can possibly avail is found sometimes in a twist of gold which has 
been thrust through the foramen in the act of filling the root. With 
this cause I have several times met, although never appreciating it 
until exhibited in the extracted tooth. 

An alveolar abscess connected with the teeth of scrofulous chil- 
dren will not unfrequently result in a necrosis exfoliating the sur- 
rounding process. A case of this kind, coming quite lately under 
my notice, resulted in the loss of quite half of the right superior 
maxilla; while a second case, occurring in a mercurialized man, 
destroyed the whole bone. 

A chronic alveolar abscess is not unfrequently found resistive to 
treatment as the result of the mechanical cause of a malarticulation, 
which keeps the affected tooth continuously worried. This is an 
offense for which we are always to examine, as it is readily induced 
by changes which may have occurred from the inflammatory asso- 
ciations. Any single tooth, however healthy, striking in its artic- 
ulation before its' fellows, will become thereby diseased. This is 
often enough witnessed where, in filling teeth, the metal has not 
been sufficiently dressed down, and is thus unduly impinged upon ; 
such teeth becoming sore to the touch, even to the result, when 
the cause is not appreciated and removed, of irritating the part 
into abscess. 

Abscess associated with the temporary teeth is always to be 
looked on with concern, the irritability and excitability of the young 



THE TEETH AND THEIR DISEASES. 181 

jaw being so great that any addition to the excitation of the dentinal 
period is found commonly to prove more than the force of the parts 
can antagonize, — thus resulting not unfrequently in extensive dis- 
organizations. Should abscess in the temporary tooth have asso- 
ciation with any of the exanthems, the immediate removal of the 
organ is made a necessity. Indeed, these infantile abscesses, how- 
ever associated, are never to be allowed to run on, but, if not speedily 
responsive to medication, should be cured by extraction of the 
offending tooth or teeth. 

As is involved the principle in the treatment of an alveolar 
abscess, it is required simply that the practitioner recognize pus as 
protoplasmic degeneration : matter breaking down because of an 
inability to organize into living tissue. Whatever shall afford or 
add the lost force must prove the cure of the abscess. To this end 
all deteriorative local causes of offense are to be removed. If a tooth 
contain a dead pulp, such pulp is to be extirpated ; if it unduly 
strike its neighbor, as just alluded to, such false occlusion is to be 
remedied ; if irritation be kept up by subjection of the membrane 
to foreign agents of offense, as a habit of biting improper articles, 
cracking nuts, untying knots, cutting threads, etc., subjection of the 
parts to rapid and great alternations of heat and cold, as in the use 
of ices and hot drinks, these and any other causes of offense are to 
have consideration. 

General indications are to restore healthy innervation, circulation, 
secretion, and excretion, by such medication, hygienic or otherwise, 
as shall tend to allay irritation, increase plasticity through tonicity, 
and restore normal action. To such an end, besides the local medi- 
cation which may be required, resort, as indicated, may be compelled 
to the employment of specifics, nervines, alteratives, astringents, and 
antiseptics. In one sentence, we are to recognize and appreciate 
the indications, local and general, and meet them. When this has 
been done, and yet a cure is not secured, the only remaining ques- 
tion is between the extraction of the affected tooth or teeth, and 
the risk of such consequences as osseous caries or necrosis, 



CHAPTER IX. 

THE TEETH AND THEIR DISEASES. 
ANCHYLOSIS OF THE JAW. 

Under, the heading of diseases of the teeth we may study the 
subject of anchylosis, inasmuch as in a knowledge of the associate 
lesions of these organs, in such direction, we seem to start from the 
most elementary foundation. 

Anchylosis of the ja,w(ayxu?,os, crooked), trismus (rp^aj, to gnash), 
finds its general nature and characteristics exhibited in the condition 
as seen in the common articular system. A special study may 
therefore be beneficially preceded by a review of the subject at large. 

By anchylosis is meant stiffness in an articulation, such stiffness 
varying to absolute immobility. The terms true and false, complete 
and incomplete, are employed to express two common groups under 
which a variety of forms are classed ; the first being applied to a 
state of fixedness in the joint, the second where more or less motion 
exists. A clinical division, however, and one the practical utility 
of which every practitioner is soon found to recognize, is consideration 
of the lesion as reference is had to its intra- or extra-articular char- 
acter; that is, whether the disease is within, or without, the joint. 

Intra-articular anchylosis implies change in the articular relations, 
arthritic inflammatory action leading to plastic effusion, which effu- 
sion has necessarily a varying history. Imprimis, a stiff joint may 
depend on a simple synovitis ; the ease of the patient compelling 
quietude in the part. It may associate, again, with lengthened 
disuse of the joint, as compelled in fracture-treatment, such fixed- 
ness acting as the abstraction of the natural stimulus of the part 
found in its motion, thus resulting in a dryness which becomes in 
time the excitant of an inflammatory exudate, with tendency to 
organization favored by the immobility. Arthritic inflammatory 
action is the history of all inflammatory action, and is to have con- 
sideration from such common standpoint. 

In any inflammation, a matter which first calls for consideration is 
(182) 



THE TEETH AND THEIR DISEASES. 183 

the character and nature of the disturbance. Such a consideration 
applies particularly to arthritis ; for whether the action arises from 
local or constitutional causes makes nearly all the difference in such 
prognosis as we may feel inclined to offer. 

Local arthritis is expressed by any cause of offense of local char- 
acter that may be discovered to have provoked the lesion ; of such 
offenses we may instance blows, luxations, fractures, immediately 
neighboring lesions, inter-articular bodies. 

Arthritis of constitutional relation finds its diagnosis in the ab- 
sence of local sources of offense, and in the presence of cachexia : 
scrofulosis, syphilis, rheumatism, gout, cancer, and the sang calcine. 
The rheumatic, gouty, and scrofulous arthrosia are very familiar 
exhibitions in such a direction. 

Complicated Arthritis.' — This refers to a provocation into action, 
by some local irritant, of an abeyant cachexia. Enough instances of 
such complications are found in the hip diseases of children arising 
from falls, and of cancers located through local injuries. 

Inflammation in a joint has primarily a double diagnostic signifi- 
cation of much concern to the surgeon; that is, the inflammation may 
involve the joint proper, bones, cartilages, or synovial membrane ; 
or it may be confined to the latter exclusively. 

In synovitis proper, the prognosis is much more favorable than in 
true arthritis, provided the attack be acute in character and the 
treatment timely. Synovitis in its incipiency is attended by excess 
in the natural secretion of the membrane, associated with more or 
less serum ; such excess, by overfullness of the articular cavity, inter- 
fering markedly with freedom of motion. Passing into a chronic 
state, the neighboring parts are soon involved, and what is to be the 
result depends as much on the circumstances of the case as on the 
care and skill employed in the treatment. Effusions in synovitis are 
readily distinguished, the serous, associated with all the phenomena 
of acute inflammation, — the parts being red, heated, painful, elastic, 
and fluctuating. The plastic exudate, appearing after the acute 
action has passed, is dull, doughy, and pitting, and divested of active 
associations. 

An attack of synovitis may be, and indeed commonly is, sub- 
acute in character, that is, it may be a long while in developing 
itself, and this, even when it is the result of local injury. The first 
symptom attracting notice is apt to be a sense of stiffness after rest, 
this being most observed in the morning; succeeding this is pain, 
with the stiffness prolonging and fixing itself; swelling will now 



184 ORAL DISEASES AND SURGERY. 

perhaps be first observed, the heat of the part increasing with the 
distention ; suffered to progress, suppuration of the membrane may 
be the result, and with it the complete destruction of the joint. A 
better and, happily, more frequent result is found in a cure of the 
inflammation through the exudative process, such exudation seem- 
ing to afford the necessary relief to the over-distended vessels. 
With such a result obtaining, the care of the surgeon becomes 
directed alone to the exudate, the absorption of the serum is to be 
compelled, and through passive motion and the judicious employ- 
ment of the sorbefacients, the plastic lymph may not be allowed to 
associate its bands with parts that shall afford it the capability of 
organization. 

Acute synovitis, if disassociated with cachexia, may commonly 
be quickly resolved into a subacute condition; to obtain such result, 
however, treatment is to be directed with much judgment; if purely 
local, the attention required will most likely be one vigorously anti- 
phlogistic ;* if conjoined with cachexia, local sedation is to have 
associated with it a constitutional specific medication, or a treatment 
of stimulation and invigoration as may be indicated. A common 
treatment for an acutely inflamed joint, whatever the parts involved, 
might be laid down as follows: Put the feet and legs in water, as 
hot as can be borne; administer a full saline cathartic, or a diapho- 
retic; apply a lead-water and laudanum lotion to the inflamed -part ; 
bleed with the lancet, or, locally, by leeches; depress the circulatory 
force by the administration of arterial sedatives, and restrict to a low 
diet; use counter-irritants ; any or all of these means being employed 
according to the indications of the case, an exception to the use of the 
pediluvium existing in inflammation of the inferior joints. An inflam- 
mation, having its acuteness broken, is often happily terminated by 
painting the parts with the tincture of iodine, or with the muriated 
tincture of iron combined with quinine and the tincture of cinchona, 
as recommended on another page for erysipelas, or with diluted 
Monsel's solution of the persulphate of iron, and afterwards, if 
deemed necessary, enveloping the part in the lead and laudanum 
lotion. Where structural change is feared as the result of effusions, 
the mercurials may be administered and pushed to the least percep- 
tible evidence of their impression. It is seldom the case, however, 
that a result is not better without than with these : it is not to be 



* A cure almost magical in the rapidity with which it results is sometimes 
secured hy cauterizing the surface with the solid nitrate of silver. 



THE TEETH AND THEIR DISEASES. 185 

doubted that through the injudicious use of this medicine many 
joints have been depressed to suppuration, which, without it, would 
have escaped. 

When, in defiance of treatment, suppuration occurs in a joint, 
the pus formed is to be got clear of as speedily as possible. To 
effect this, it is perhaps not possible to adopt a better plan than the 
subcutaneous valvular puncture, to be made by using a delicate 
tenotome. Such a valve may be opened as often as the pus reaccu- 
mulates. At this stage it is also that we may resort to direct stim- 
ulation with prospects of good results. Yet what is to be the precise 
nature and extent of such stimulation is not so easy to suggest, each 
case having, most likely, some special indication. The principle 
of the means, however, would be found in anything that should 
arouse the parts to a higher and healthier grade of action ; stimu- 
lating embrocations, hot or cold douches, strapping, painting as 
before suggested, passive motion, or even, it might very well be, in- 
jections into the joint itself, — a means that might save the articula- 
tion where all others should fail. 

Synovitis having a systemic origin demands that the treatment 
consider the specific indications. If syphilitic, gouty, rheumatic, or 
strumous, medicines which experience characterizes as most antago- 
nistic to these conditions must be conjoined with the local means. 
Thus, while giving every attention to the affected joint, we direct 
a medication to the cause at large. 

Arthritis. — By arthritis is meant the inflammation of the common 
structures of the joint; here the danger of ill results is proportion- 
ally greater than synovitis as extent of parts is involved. An 
arthritic inflammation may be general, involving all the components 
of a joint, and of such severity of grade as to run quickly into sup- 
puration and destruction of the parts, or, on the contrary, it may 
prove so slight as not to amount to anything more grave than a 
temporary congestion resolvable by a few hours of rest and seda- 
tion. Between these two extremes are found all the phenomenal 
associations of inflammatory action. An arthritis in the fullness of 
its history might be thus described : First, a sense of stiffness in 
the joint, with increasing uneasiness, — the stage of simple vascular 
excitement. Second, the development of the sense of heat, the parts 
swelling and becoming intensely painful on the slightest motion, — 
the stage of active congestion. Third, fixed engorgement, the pain 
persistent and of a heavy character, skin a dull red or white, accord- 



186 ORAL DISEASES AND SURGERY. 

ing as the inflammation may or may not have traveled to the sur- 
face, — the stage of stagnation. Fourth, the destruction and breaking 
down of the involved parts, — necrosis, as evidenced in morbus cox- 
arius, — the stage of suppuration and devitalization. Fifth, hectic 
fever from exhaustion, or pyemia from pus poisoning. Sixth, death. 

The treatment of arthritis proper is precisely that indicated and 
employed in synovitis. To limit and control inflammatory action 
is the principle of the cure. The vigor with which such a treat- 
ment is to be directed depends, of course, on the indications of each 
special case, these presenting, as suggested, every shade of char- 
acter. If an inflammation, in defiance of the immediate antago- 
nists employed for its control, pass onward in its grade to the 
effusion of lymph, as recognized by the doughy, pitting character of 
surrounding parts, then the danger of anchylosis, on the one hand, 
or of the degeneration of this agent into pus, on the other, is the 
matter which presses for attention and concern. Passive motion 
of the gentlest character is to be resorted to, together with the 
employment locally of sorbefacients, combined with such general 
medication as the particular case may appear to demand. If the 
mercurials seem essential, the practitioner will seldom find himself 
at fault in combining tonics with them. This will most certainly 
be found to hold true in all cases associated with asthenia. The 
character of cases in which it would seem to my judgment that the 
mercurials are admissible, and, indeed, in some instances, positively 
necessary, is that where the trouble occurs with the robust and 
vigorous. In cases of this class their good effects are occasionally 
markedly observed ; but even here, if they be employed too freely, 
the harm done quickly overbalances the good. When a mercurial 
is used, the effects produced are to be watched with the closest 
attention, and never is it to be inferred that, because good effects are 
observed from the gentlest of ptyalisms, a pushing of the medicine 
will expedite the cure. No greater error than this can arise ; a result 
is not unapt to be pus, and the destruction of the joint. Another 
matter, not to be overlooked in the employment of this medicine, is 
its cumulative nature. A man may take a mercurial for a week or 
a month without apparent effect, when suddenly the most profuse 
ptyalism will exhibit itself. I have seen this again and again with 
patients under treatment for syphilis. 

Rheumatoid Arthritis. — For a medical paper treating most fully 
on this condition, the reader is referred to Reynolds's System of 
Medicine, vol. i. p. 913. 



THE TEETH AND THEIR DISEASES. 187 

Trismus. — This term has its application alone to the anchylosis 
of the ternporo-m axillary articulation ; it expresses the simple lock- 
ing or fixing of the jaws. As there are many causes or conditions 
involved in such locking, so, of course, we have conjoined terms 
expressive of such different lesions: trismus traumaticus, including 
tetanus, — the locked jaw from wounds and other local external inju- 
ries ; trismus dentium, arising from associative dental lesions; tris- 
mus nascentium, or trismus neonatorum, — infantile tetanus. In 
strictness of application, the term trismus, however, applies only to 
gnashing, spasmodic, or nervous lockjaw, and is without true expres- 
sion or meaning when applied to other forms. It might be best 
viewed as referring to the medical rather than to the surgical aspect 
of the lesion. 

Tetanus — from -eivu), to stretch — is a disorder of the nervous 
system, presenting its manifestations in spasms, and affecting in 
nearly every instance the muscles of mastication, thus producing 
gnashing, or, it may be, locking of the jaws. Tetanus is decidedly 
a nervous disease in its expressions, and is primarily confined to 
the true spinal system, being produced in some individuals by the 
most trifling injuries, many cases being on record where the simple 
extraction of a tooth has sufficed to provoke it. The terms opisthot- 
onos, emprosthotonos, and pleurosthotonos are employed, together 
with trismus, to designate the groups of muscles implicated in the 
derangement. 

Tetanus is divided into traumatic and idiopathic, and into acute 
and chronic; the first following wounds and other injuries, the 
second arising without assignable cause. The first form is usually 
acute in character ; the latter is apt to be chronic, and, to the extent 
of its chronicity, amenable and responsive to treatment. 

As predisposing causes of tetanus, the experience and observations 
of Baron Larrey would seem to give cold and dampness prominent 
positions. Dr. Kane, in his Arctic Explorations, alludes to the death 
of two of his men from tetanic spasms, after being exposed to intense 
cold. Extreme heat is certainly another of such predisposing causes, 
tetanus being as common in the very hot as in cold temperatures, 
both extremes acting, most likely, by provoking centric nervous irri- 
tation. 

Symptoms. — Tetanus, although sometimes coming on suddenly, 
has more commonly a premonitional history. Instances are recorded 
where the spasms have arisen almost simultaneously with the recep- 
tion of a wound. Such cases are, however, exceedingly rare, and 



188 ORAL DISEASES AND SURGERY. 

indicate a predisposition which renders the disease almost neces- 
sarily fatal. On the other hand, it is exceedingly common to find 
the condition remaining in abeyance until the external wound has 
completely healed. A case of this latter character came only a 
short time back under my own immediate observation, where a lady, 
while searching in a barn for eggs, accidentally ran a rusty nail 
into her knee, not, however, penetrating the articulation. Four days 
after the reception of the injury, with the break fairly healed, em- 
prosthotonos supervened ; yet the spasms quickly disappeared upon 
the opening of the wound with a bistoury and the introduction of a 
delicate tent, thus compelling a filling up of the parts from the bottom. 
The irritation of a nerve radicle by its being caught and compressed 
in a cicatrix is a reasonable explanation of neuralgia and tetanus 
supervening on the healing of a punctured or lacerated wound, and 
seems to have had an example in this case. 

Commonly, tetanus exhibits its approach, as suggested, in a 
gradual manner. Attention is first directed to a sense of general 
malaise ; then supervenes stiffness of the movements of the lower 
jaw, as though the muscles were exhausted. This stiffness, in- 
creasing to soreness, extends to the muscles of the neck. The 
mouth becomes dry and sore; mastication grows painful, and 
swallowing difficult, a sense of spasm and suffocation resulting 
when these offices are attempted. Eventually the masseters, tem- 
porals, and pterygoid muscles become stiffened and bulging; the 
orbicularis puckered and contracted ; the eyelids are closely approxi- 
mated ; the zygomatici are liable to become fixed, thus giving a 
peculiar expression known as the Risus Sardonicus. Following 
these symptoms, almost any of the voluntary muscles may become 
implicated, the abdominal group, particularly the recti, corrugating 
and knotting themselves. Colicky symptoms soon supervene, in- 
duced by spasms of the muscular coat of the bowels ; or difficulty 
in respiration may arise, from spasms of the diaphragm. Opis- 
thotonos, emprosthotonos, pleurosthotonos, or, it may be, a most un- 
yielding trismus now develops, according as the force of the irritant 
may select special groups of the muscular system upon which to 
expend itself. That tetanus does not implicate the ganglia of 
special sense, but is confined to the spinal cord, medulla oblongata, 
and cerebellum, is demonstrated in a clearness of the intellect which 
continues during the attack. 

The bowels, in tetanus, are commonly found obstinately consti- 
pated, depending on the general derangement of the alimentary 



THE TEETH AND THEIR DISEASES. 189 

canal; and motion, when it does obtain, is accompanied with fetor 
of a most offensive character and great persistence. The bladder 
may be closed by spasm of the muscular fibres of its neck, or these 
may be so relaxed that complete incontinence exists. The tongue, 
when involved, tends to be thrust forward, and is thus often lacer- 
ated in the spasmodic occlusions of the teeth. 

Acute tetanus seldom has a greater duration than four days, the 
patient perishing either from asphyxia in a spasm, or otherwise from 
exhaustion. Chronic tetanus, on the contrary, runs on day after day, 
most frequently eventuating favorably. One is impressed with the 
sense of a battle, in which nature properly supported may reasonably 
be expected to win. 

Pathology. — Because of the absence of definite pathological lesions, 
more or less diversity of opinion exists concerning the conditions of 
this disease. Sporadic or traumatic cases, where tetanus has shortly 
supervened upon injury to a nerve, naturally direct attention in such 
direction. Investigations into nerve-relations, however, prove so 
unsatisfactory that there seems now quite a tendency to revive the 
humoral origin, a view maintained with all earnestness by Rose, 
and favored by both Billroth and Dr. Richardson, the latter sug- 
gesting that it may eventually prove to be the result of the absorption 
of some septic material. " In this disease," says this author, "the 
poison, in my opinion, is first developed in the wound as the result 
of decomposition. Thence carried into the circulation, the new 
substance, without any necessary increase of its own parts, excites 
a zymosis, ending in the production of an alkaloidal or alkaline body, 
which has all the power of exciting the symptoms of spasm as much 
as strychnine itself." Billroth inclines to ally the condition with 
the infectious phlogistic. " It is known," he says, "that, by blood- 
poisoning with strychnia, severe spasms, and with alcohol, psychical 
disturbances (drunkenness), may be induced ; hence it is very possi- 
ble that this disease may result from poisoning with a peculiar sub- 
stance, only very rarely formed in wounds, and thence absorbed." 

The symptoms of tetanus indicate irritation of the spinal medulla. 
Rokitansky describes, from autopsies made by him, evidences of vas- 
cular relations of this substance as exhibited in the development of 
young connective cells. Other observers, however, have failed to 
find these expressions. 

The reviewer of the article Tetanus in Reynolds's " System of 
Medicine" (see British and Foreign Medico- Chirurgical Review, 



190 ORAL DISEASES AND SURGERY. 

vol. xiii.) says, " The author does not attempt to trace any connec- 
tion between the acknowledged causes, cold and damp and wounds, 
and the production of such a fearful consequence in only a few cases. 
With regard to its relation to hydrophobia and analogy of the 
latter to that of snake-bites, may not the connecting link between 
chilled wounds and spasmodic paroxysms be an animal poison gen- 
erated in the wound during the process of healing? and being an 
animal poison, therefore poisonous in extremely minute doses ? and 
being an animal poison, therefore latent in the system for long 
periods ? and being an animal poison, therefore specially fatal to the 
nervous system ? The greater tendency in punctured and closed 
wounds to cause tetanus is very suggestive of the needle-like ser- 
pent's fang, and the frequent triviality of the dog's bite, which are 
more deadly the less blood flows." 

Holmes (in his chapter on Tetanus ; see vol. i. p. 330), after a review 
of the morbid anatomy, as referred to by various observers, remarks 
the obscurity in which the pathology is involved. " Some," he 
says, " are seen to affirm tetanus to be an irritation of a peculiar 
kind, affecting the excito-motory apparatus ; that the irritating cause 
may be excentric at the extremity of, or in the course of, the afferent 
spinal nerve, or it may be centric within the spinal canal itself. 
Some consider it to be an exaltation of the polarity of the cord and 
medulla. Others, again, maintain it to be identical with inflamma- 
tion of the spinal cord and medulla oblongata, and adduce cases of 
inflammation of such structures as inducing symptoms of tetanus." 

Principles of Treatment. — " If the difficulty of ascertaining patho- 
logical conditions, upon which all rational indications of cure should 
be based," says Dr. Copland, "be so great in this malady as not to 
have hitherto been overcome, can it be a matter of surprise that the 
means which have been resorted to, both by physicians and sur- 
geons, in its treatment, have been most opposite in their effects, the 
most different in their nature, and in every respect most empirical 
and uncertain ? In this state of our knowledge, it would be better 
to leave nature to her unaided efforts, to observe closely and accu- 
rately what is the true procession of changes and of their manifesta- 
tions, and to ascertain the seats and the extent of lesion as soon 
after death as may be attempted with propriety." 

The treatment that has most commonly suggested itself seems to 
be that of anaesthesia, opium and chloroform being much depended 
on. Of the former medicine as many as twenty or more grains have 






THE TEETH AND THEIR DISEASES. 191 

been used in the course of a day, or a correspondence in the subcu- 
taneous use of morphia. The greatest gain in treatment seems to 
be to prolong the disease into chronicity, thus wearing out, as it 
were, the force of the active cause. Billroth refers to the use of 
warm potash baths, and the application of strong irritants along the 
spine, large blisters, moxaB, but does not feel that experience tends 
to indorse any of them. On the contrary, referring more particu- 
larly to the chronic cases, he suggests that the patient be allowed to 
remain as quiet as possible, guarded against all injurious influences, 
especially from physical or mental excitement, the general aim of 
the treatment, he thinks, being to alleviate the acute course and 
make it more chronic, as this gives more hope of recovery. 

Of the internal remedies that have been employed, almost every 
class and description have been tried, without, as yet, any result in 
the way of a specific or an approach in such direction. " Altera- 
tives, in the shape of the varied preparations of mercury, large doses 
of fixed alkalies, solutions of arsenic, etc. ; diuretics, in the form of 
tincture of cantharides, oil of turpentine, given in frequent and large 
doses so as to irritate the urinary passages or to occasion bloody 
urine ; sedatives, such as digitalis, tobacco, nicotina, hydrocyanic 
acid, aconitina; anodynes and narcotics, as opium, morphia, bella- 
donna, colchicum, cannabis indica, ether and chloroform internally 
and by inhalation ; stimulants and antispasmodics, including musk, 
ammoniacum, camphor, turpentine, assafetida, castor, wine, and 
other stimulants ; tonics, such as quinine, bark, strychnia, iron, 
zinc, etc. ; hygienics and dietetics, as support, milk-diet, etc. ; injec- 
tions into the veins of solutions of opium, stramonium, etc. ; tra- 
cheotomy and laryngotomy. The calabar bean in sufficient doses to 
paralyze the voluntary muscles has been affirmed to be attended with 
marked success, although it has, on the other hand,* failed very fre- 
quently." (Alfred Poland, Holmes's "System of Surgery.") 

The treatment of tetanus by woorara has of late excited some 
attention, mainly through the work of Mr. Morgan. According to 
Demme, this most powerful poison has out of twenty cases resulted 
in eight cures. It is recommended by Spencer Wells, Broca, Chas- 
saignac, and others ; the dose is given as from one-eighth to one-half 
grain to an adult. To one not familiar with the action of woorara, it 
would seem necessary to recommend great caution in its employ- 
ment. Most interesting experiments have been performed with 
woorara upon the lower animals, particularly a series in 1858 by 
Dr. J. J. Woodward. 



192 ORAL DISEASES AND SURGERY. 

The use of the calabar bean has come to be much relied on in the 
United States. Eighteen cases are reported by Dr. Eben Watson 
in which this medicine was used, yielding ten recoveries. The dose 
varies with the effect produced in controlling the spasms. The action 
seems to be that of a direct sedative to the spinal cord, patients, 
while under its influence, commonly taking food with ease. One 
grain may be commenced with as a dose, increasing the quantity 
pro re nata. 

The new preparations hydrate of chloral and croton-chloral have 
in them considerable promise in this direction. A peculiar action 
from this latter agent is found, that at first a high degree of anaes- 
thesia in the head is produced, while sensibility in other parts of the 
body remains intact. The second stage is,- that the spinal cord 
loses its function, and reflex excitability is everywhere extin- 
guished. During this stage, pulse and respiration remain unchanged. 
The third stage, which is induced by large doses, is characterized 
by paralysis of the medulla oblongata, and death. Animals may, 
however, be kept alive by artificial respiration, because the function 
of the* heart is not interfered with ; while the ultimate effect of 
hydrate of choral is to paralyze the heart. 

The local treatment which has been had recourse to in tetanus 
consists in laying open wounds, their thorough cleansing, and the 
application of antiseptics; division of nerves, the application of 
counter-irritants, the employment of sedatives, ice-bags to the spine, 
cold and warm shower-baths, electricity, attention to inflamed and 
suppurating wounds, etc. 

Trismus Nascentium. — Lockjaw in new-born children. — The fre- 
quency of this condition, and its fatality to a particular order of 
infantile life, make its study one of interest and importance to the 
practitioner, ft is decidedly a disease associated with the period 
of the desiccation and phenomenal change occurring with the cord 
and umbilicus, and is found confined, therefore, to the time associ- 
ated with these changes, — never occurring before the second day 
after birth, and seldom after the fourteenth. 

Tetanus, of which this is a form, has its expression and association 
exclusively with the nervous system of organic life, — the excito- 
motor. That trismus nascentium is therefore a special disease, is 
not to be entertained for a single moment; it is simply tetanus 
occurring from generally evident causes in the newly-born, and is to 
have the consideration and treatment of the disease as found any- 
where else. Wherever the nervous system of organic life exists in 



THE TEETH AND THEIR DISEASES. 193 

exquisite development, and wherever it is excited from any cause to 
excess of expression or action, there is found the danger of trismus. 
Hence in infants of the negro race, and particularly those born 
of parents of less than average intelligence and resident in hot cli- 
mates, the condition is found most widely to prevail. In the southern 
section of the United States, and in the West Indies, the mortality 
of infantile deaths from this single cause is estimated by some 
observers at not less than twenty-five per cent. ; while it is affirmed 
that in the equatorial regions of South America in some years 
more than half the infants born fall victims of this disease. In an 
epidemic form in which it is found occasionally to prevail, the mor- 
tality of certain neighborhoods has amounted to four-fifths of the 
births. 

That trismus nascentium is not confined, however, to the hot lati- 
tudes is to be inferred, not only from the report of many cases else- 
where, but from its oneness with tetanus proper. According to 
Dr. Holland, it is very prevalent on the southern coast of Iceland, 
also at St. Kilda, one of the western islands of the Scottish coast. 
In Elbing, Prussia, cases are announced as occurring frequently, 
thirty-seven being recorded from 1863 to 18G5 in a population of 
twenty-seven hundred. In Dublin, the disease has prevailed so 
alarmingly that at one time, for a limited period, nineteen-tvventieths 
of the infantile deaths occurring in the Lying-in Hospital of that city 
were from this cause, the death-rate being one to every sixth child 
born. Being attributed to ill ventilation and the absence of proper 
hygienic requirements, attention was at once directed to these pro- 
phylactics, with the result of decreasing the rate to one in nineteen. 

Symptoms. — Like the manifestations of the disease as exhibited in 
the adult, the prodromous period may be deficient in signs sufficiently 
marked to attract ordinary observation. The child may seem rest- 
less and more excitable than usual, but this is apt to be attributed 
to any other than the true cause. A few hours, or it may be days, 
intervene, when the infant, apparently anxious for the nipple, is 
found unable to take hold of it, This, together with an occasional 
smothered cry, as if the child was in distress, first brings it under 
the notice of the physician. 

If now the jaws be examined, more or less rigidity will be found 
to exist, the masseter muscles seeming the ones principally affected. 
From these the expression may extend to any others, and does 
so in a very few hours ; or it may be that the first manifestation of 
muscular involvement is exhibited in spasm, the jaw being shut with 

13 



194 ORAL DISEASES AND SURGERY. 

a snap which has, in instances, partially amputated the tongue ; or 
the spasm may affect some muscle of the limbs or trunk. Such 
commencement of the active stage of the disease is, however, 
infrequent. 

In the fully-developed stage of infantile trismus the spasms are 
found quite frequent. The agitation of the child is very great. ' The 
smothered scream which it emits is peculiarly painful, — itself spas- 
modic in character from affection of the respiratory muscles. The 
little sufferer foams at the mouth ; the fists are tightly clinched ; the 
feet are flexed upon the ankles, with the great toe abducted ; the 
head is drawn back by the cervical muscles ; the surface grows livid, 
the infant dying in the paroxysm, or, otherwise, either receiving 
respite in which relaxation ensues, or sinking into death through 
coma. The duration of the disease is commonly about two days; 
but cases are recorded where death has not occurred until the third 
week of the attack. 

Causes. — First, there may be assumed to be a predisposition 
(though this need not of necessity exist), such predisposition being 
impressed on the child in utero by the hot and foul air and common 
filthiness of habit which, from its inception, have attended it in the 
person of the parent who has borne it : this finding proof in the fact 
that as the condition of parents has been improved, so has trismus 
diminished, the disease finding its habitat almost exclusively amidst 
the squalor and povert}^ of the lowest and least intelligent classes. 
Other predisposing causes are found in any and all relations of de- 
pressing character. Thus, hot moist days, followed by cold nights, 
have been sufficiently recognized to be among the most efficient of 
the predisposing causes, the explanation being found in the inter- 
ruption of the functions of the skin. Miasma, no doubt, contributes 
its quota through its depressing action on the nervous system, — 
tetanus being associated with the period of reaction. 

In papers published in 1846 and 1848, Dr. J. Marion Sims ad- 
vanced the view that the cause of trismus nascentium lay in a 
pressure exerted on the medulla oblongata and the nerves originating 
from it, produced by displacement of the cranial bones, and espe- 
cially the occipital, such displacement occurring in the parturitive 
effort, and capable of being corrected ; but that the cases observed 
by him were exceptional, and not common, seems clear enough by 
the universal denial of his premises, following observations elicited 
by the publication of his views. 

Whatever, then, maybe a predisposing cause of infantile trismus, 



THE TEETH AND THEIR DISEASES. 195 

the chief exciting one is found in association with the umbilical cord: 
and first this associates with the tying and excision of it. A cord 
cut with a dull blade may be thus put into a condition of irritability, 
which, reacting upon a highly predisposed system, might bring 
on an immediate attack of spasm. An ill-strangulated cord may 
be classed as the second of the offending causes. A common habit 
with mid wives among the poorer classes is to wrap the parts with 
packthread. This is not only an inadequate protection against 
hemorrhage, as in my experience I have several times had occasion 
to witness, but it is irritating to the parts even in the remote aspect 
of its relation with the general system, and may readily arouse the 
abeyant irritability^. 

The umbilical cord separates from the body, physiologically 
speaking, as does the stem from the ripe fruit. When such is not the 
character of the disjunction, the conditions are to be expressed as 
pathological, being associated with more or less inflammation, ulcer- 
ation, and local irritation. The ordinary period required for the 
separation of a funis is from three to six days. During this period 
the parts should be kept enveloped in a fold of old half-worn linen, 
prepared as a dressing by snipping a piece out of the centre after 
the manner of the Maltese cross ; the cord to be passed through this 
hole, and thus, by its envelopment, separated from contact with the 
person of the child. In hot climates, such dressing, combined with 
oil, or antiseptics, is the more necessary, as the danger is to be 
guarded against of having the parts serve as a habitat for the 
deposit of larvaa, — a not infrequent cause in itself of tetanus. 

Treatment. — From the constitutional standpoint, nothing more 
may be done than is to be inferred from the directions given in 
general tetanus. Anodynes, antispasmodics, anaesthetics, and altera- 
tives, these we may try ad libitum, but the result will amount to 
very little if any unappreciated or unremoved cause exists in the 
way of local irritation. Attention is therefore to have a first direc- 
tion to the umbilical region, and such attention, if directed in the 
incipient stage, may not unfrequently result in aborting the attack. 
If an ill-incised cord be found, make at once a fresh and clean cut 
nearer the bod}^. If the cord is indifferently strangulated, remove 
at once the ligature, and replace with a well-waxed silk thread, or 
otherwise place a new ligature nearer the body. If separation of 
the funis is not progressing with its usual physiological harmony, 
then treatment will be needed as indicated. Cleanliness is to be 
strictly enjoined, and vascular action is to be stimulated or depressed, 



196 ORAL DISEASES AND SURGERY. 

as required, — not as indicated by the pulse, for this in tetanus affords 
very little guidance, but, as implied, at the seat of local offense. 
Among negroes, as remarked by Dr. James S. Baily, whose oppor- 
tunities for observation seem to have been extensive, "the unclean- 
liness and unsuitableness of the umbilical dressings are by far the 
most common of the exciting causes of the disease. Among these 
people infants are found not only fetid with the ammoniacal smell 
of the urine with which they are wet from morning until night, but 
are loaded with fecal matter, so thoroughly saturating the appendage 
of the funis as to render its drying impossible. In consequence of the 
sphacelated condition of the cord, it gives off the material of death 
and decay, which, being deposited in direct contact with the active 
absorbents, must necessarily act as a fearful causation." This gen- 
tleman, who, during a residence in Texas, was able to collect and 
make notes of two hundred cases, tells us that in his experience he 
has never observed a case of lock-jaw when due regard was paid to 
proper instructions in reference to the management and dressing of 
the umbilicus. Tumefaction and redness without suppuration are 
always, he thinks, expressions to excite apprehension, and are to 

receive immediate attention. Quoting a Mrs. , a lady living 

on the Brazos, in Texas, observation is directed to the value of a 
mush poultice applied to the navel immediately after birth, to be 
continued until the falling off of the cord, or while any signs of in- 
flammation exist, the lady asserting that with such practice employed 
with her own servants they have never lost a case. This, however, 
evidently applies to the use of the poultice as a prophylactic, — a 
direction, indeed, in which the physician finds himself most useful. 

TRISMUS DENTIUM. 

In the chapter on Dental Anomalies we studied the process of 
maxillary enlargement, and understood how that process was, in 
part, counterbalanced by an untimely extraction of the deciduous 
teeth. It was further shown how certain derangements of the 
dental organs were a common, if not a necessary, sequence to such 
abridgment of the arch ; and, among other ill effects, reference was 
made to the impossibility of a natural and healthy evolution of the 
wisdom teeth, and to conditions favoring periodonteal inflamma- 
tion. In this section we are to consider lock-jaw as it has a signifi- 
cation exclusively surgico-dental. 

Such dental signification, however, will, I apprehend, outside of 



THE TEETH AND THEIR DISEASES. 197 

tetanic conditions proper, be recognized to have the widest relation- 
ship to the lesion, and, indeed, if my experience has not been un- 
commonly one-sided, it will be found to have the very closest rela- 
tionship; for I incline to think that, in every twenty cases of local 
trismus, eighteen have, as the primary lesion, periodontitis, in some 
of its varied forms. 

We have considered the retraction of the dental arch. We will 
now look at such lesions as this retraction has engendered — lesions 
pertaining to the subject under consideration. 

The troubles of an individual afflicted with a contracted dental 
arch are most apt to begin at about the fifteenth or sixteenth year of 
age. If you look into such a mouth you will find the teeth crowded 
together in most uncomfortable-looking positions. The last molar 
of the lower jaw you will see, quite likely, jammed into the ramus; 
while the same tooth of the superior jaw will be found occupying 
the very extreme of the tuberosity of the bone. 

At this period, unless, fortunately, the teeth are possessed of un- 
common resistance, you will find them breaking down from approx- 
imal caries; while, as the result of such caries, combined with the 
crowded condition of the fangs, the alveolo-dental periostea enter 
into a subinflammatory state, and become as ready to take on acute 
disease as is tinder to respond to a spark. 

If, then, interference with the elongatory process has been such 
as to yield these troubles when only twenty-eight teeth have 
erupted, it is plain to infer that the development of the four dentes 
sapientias must proportionally add to the difficulties. And only 
by appreciating the character of such trouble can we fit ourselves to 
abort its lesions. 

These lesions are periodontitis, alveolar abscess, stomatitis, ostitis, 
necrosis, trismus, etc. 

In the chapter on Anomalies, it was remarked that all dental trou- 
bles arising from retraction and diminution of the maxillary arch 
could be guarded against by a timely extraction of certain of the 
permanent teeth ; and from this we might infer that troubles arising 
from an advancing wisdom tooth might also be provided for on the 
same principle, namely, by extracting the second molar, thus se- 
curing the required alveolus. 

These pathological conditions, and the remedial and prophylactic 
indications so plainly written over them, it would seem impossible, 
because of their very simplicity, to overlook ; that they are over- 



198 ORAL DISEASES AND SURGERY. 

looked, however, is too evident, from their many secondary lesions 
which the surgeon finds himself constantly called on to treat. 

The view was advanced that the majority of the cases of trismus 
would be found to have, as the primary lesion, some periodonteal 
trouble. Of course I would be understood as not including trismus 
neonatorum, or any trismus traumaticus, the lesion of which was 
self-evident. A child might get a severe burn on the cheek, and 
trismus be a result of the innodular tissue, which w^ould close up 
the break in the continuity. Anchylosis might exist, the sequence 
to articular disease, as we have studied. Traumatic tetanus affect- 
ing the muscles of the jaw has, as we know, a primary lesion com- 
bined with peculiar nervous disturbances, which would give the 
diagnosis. But it is to the numberless cases of so-called idiopathic 
trismus I allude, and to the cases of trismus which have evidently 
a local signification alone ; that signification not being always very 
evident, or otherwise associated with so many complications as not 
to be readily distinguishable. 

Reports of case after case of unappreciated local trismus come to 
our attention, — of the lesion being referred to this cause and the 
other cause, — the treatments being as various as the diagnoses. 
Many of the inferences thus presented are, without doubt, just and 
reliable ; but I would give it as a reliable experience that where, 
personally, I have had the opportunity of seeing such cases as would 
seem to be their parallel, I have mostly been able to point out to the 
practitioner exhibiting the case, as the primary lesion, some dental 
disturbance, simple or obscure. 

In the epitome of Braithwaite, vol. ii. page 191, is a case, the 
diagnosis and treatment of which will serve as an example. Dr. 
Sellers, the practitioner who reports it, ascribes the trismus to a 
complication of inflammatory and nervous derangements. Now, 
while I might have found myself wrong, yet from the history, and 
from the age of his patient, I should have expected, had I seen the 
case with him, to be able to point out that an ulcerated sore throat, 
to which he alludes, had its primary lesion in a periosteal trouble 
of the alveolo-dental membrane; let the reader, however, draw his 
own inference. I will compare with this case one from my own 
practice. 

Dr. Sellers's Case. — Acupuncture in Protracted Lock-jaw. — The 
patient, twenty-five years of age, unmarried, had for years been sub- 
ject to attacks of suppurating sore throat, in which the jaws often 
became nearly immovable for two or three days before the discharge 



THE TEETH AND THEIR' DISEASES. 199 

of matter. In 1826, she had a severe attack, from which resulted 
complete lock-jaw, accompanied with hysterical symptoms, which 
attack yielded, after six weeks of treatment, so far that she could put 
a teaspoon in her mouth. After nearly a year, the jaw again be- 
came completely fixed, without accompanying sore throat, and the 
same treatment, with galvanism, was tried without effect. Although 
unequivocally connected with hysteria, there was reason to think, 
from the inflammatory action with which the disease set in, that 
the affection was not purely spasmodic, but was kept up by the 
rigidity of the muscles closing the jaw produced by inflammation; 
in consequence of which the antagonistic muscles had become in- 
adequate to the effort of opening the mouth under the mere influence 
of volition. 

It was this view of the case which made Dr. Sellers think it 
more reasonable, in making trial of the needles, to insert them 
into the muscles opening the jaw, in the expectation of exciting 
them to such a contraction as might overcome the rigidity of their 
antagonists. 

On each of the two following days two needles were inserted, 
one on each side of the mesial line between the chin and the hyoid 
bone, the effect being short, convulsive efforts. The teeth began to 
grate on each other, and the jaw was drawn from side to side, not 
by single alternate contractions, but by severe convulsive move- 
ments on one side, followed by a nearly equal number toward the 
other side, interrupted occasionally by a momentary opening of the 
mouth to the extent of about two fingers'-breadth. 

The convulsions continued after the needles were withdrawn; 
ceased and became renewed again after a few minutes, and returned 
spontaneously in the evening on both occasions. Some increase of 
voluntary power over the jaw followed both applications of the 
remedy. After each trial of the acupuncture some improvement 
was observable ; but, as the spontaneous convulsion was almost 
always followed by a slight loss of motion, the progress made was 
slow. 

The needles were usually inserted to the depth of half an inch, 
and sometimes to the depth of an inch. 

The acupuncture, together with leeches, was used for ten days, 
by which time the patient could open the mouth two fingers'- 
breadth and chew soft substances. She then went into the country 
for five weeks, by which she derived great benefit; but, being ex- 
posed to cold and wet on her return, had another severe attack, the 



200 ORAL DISEASES AND SURGERY. 

consequence of which was the loss of much of the voluntary power 
over the muscles of the jaw. The needles were again resorted to, 
with the same effects as before ; but the pain produced by the 
spasms was greater, and lasted longer, while the spontaneous 
convulsions recurred several times in the evenings after each of the 
first trials. As leeching did not succeed in mitigating these con- 
vulsions, the temporal artery was opened with the desired result, 
and with the effect at the same time of restoring, to a considerable 
extent, the sight of the right eye, which she almost lost with the 
first attack of lock-jaw. A second detraction of blood from the same 
vessel diminished the force of the attack so much as to permit 
the acupuncture to be used twice a day. Nine days after the re- 
newal of the operation, the jaw had recovered its natural extent of 
motion. 

The aphonia, which had come on at the same time as the affec- 
tion of the eye, was completely cured by a smart shock of elec- 
tricity. 

The case referred to as from my own experience occurred in the 
practice of a friend, — my relation with it being in a consultation. 
Its history is as follows: 

For a period of several years the patient, Mary C, twenty- four 
years of age, had been troubled with attacks of sore mouth and 
throat whenever she unduly exposed herself; these attacks had 
always associated with them partial loss of voice and general ex- 
citation of her whole nervous system, while her jaws were invaria- 
bly stiffened to a greater or less extent, according to the severity of 
the attack. 

On each of these occasions she had depended for relief upon 
domestic treatment or homoeopathy. At the period, however, of her 
coming under the care of my friend, Dr. W., she was suffering from 
such severe trouble as to decide her usual attendant into dismissing 
the case. Her jaw had remained so firmly locked for a period of six 
weeks that it was with difficulty a knife-blade could be introduced 
between the teeth. This particular spell had come on as usual ; 
but the patient said there was something about it which made her 
think that her teeth were implicated ; she could not say what tooth 
or teeth, but thought it was one or more in the lower jaw. 

Now, whatever was to be discovered as the primary lesion in the 
ease, its surgical feature, as it presented itself to our attention, 
was an extra-capsular mass of coagulated lymph about the temporo- 
maxillary articulation, which overbalanced the influence of the de- 



THE TEETH AND THEIR DISEASES. 201 

pressor muscles, holding the parts, of course, in a state of false 
anchylosis. 

I asked the patient if, when these attacks came on, her face had 
not always swelled more or less. She said that it had. I asked her 
if the cheek had not always a stiff, hard feeling in it, which wore 
away gradually after such attacks. It was so, she told me. 

Dr. W. agreeing with me that the speediest way of overcoming 
the trismus was by mechanically breaking up the adhesions, I pro- 
cured a pine stick about a foot in length, tapering, wedge-shape, 
from an inch and a half base. The thinnest portion of this wedge 
was, after much trouble, passed between and across the dental 
arches, and, after being forced a little farther on, the stick was 
turned on its axis, the adhesions yielding before the strain. Thus 
the mouth was opened at least an inch, and Ave were enabled to 
explore this cavity for the lesion upon which the trouble depended. 

So far this case will be seen to similate closely that of Dr. Sellers, 
— sore throat, aphonia, hysteria. 

Now, here we found all the trouble emanating from a wisdom 
tooth projecting, as it were, from the very angle of the jaw, and 
half covered in by an operculum of gum drooping over on it from 
the ramus. The tooth of course we at once removed. The patient 
was then dismissed for the day, a sorbefacient being directed for 
external application. 

The next afternoon, at four o'clock — no inflammation having super- 
vened — we completed, by our mechanical appliance, the unlocking 
of the jaw. In a week the patient was dismissed well. She has 
since had no return of her spells, and I am perfectly sure will not 
have. 

I think a parallelism between these two cases will be recognized; 
but should the reader disagree with me, the study of them will not, 
I trust, be without its profit. 

One of the most severe cases of inflammation of the mouth, throat, 
and face, combined with a bad trismus, I have ever seen, was in the 
person of a medical student in the office of a Dr. C, of this city — 
the primary lesion being such a half-erupted wisdom tooth as has 
been alluded to as being found in the preceding case. This gentle- 
man, when I first saw him, had been suffering for two or three 
weeks. The operculum of gum had been split up on two different 
occasions. Antiphlogisticsin every form had been resorted to. The 
patient came to me under the anticipation that nothing could save 
him from necrosis of the angle of the bone. 



202 ORAL DISEASES AND SURGERY. 

I gave this man one and a half pounds of ether; it seemed im- 
possible to get him into an anaesthetic condition, his physical suffer- 
ing was so great. Prying his mouth open, just sufficient to introduce 
the key of Garengeot, I extracted, with much difficulty, the offending 
tooth. In three days he was again attending to his studies. 

This peculiar lesion of a half-erupted wisdom tooth may well 
claim a moment's attention. Many a practitioner has been so 
deceived by the anomaly as to have been led widely astray in the 
study of his cases. 

Where this condition exists, you will notice, on looking into the 
mouth, that only the anterior face of the tooth has fairly erupted, 
the other two-thirds being overlaid by the integuments of the ramus. 
You infer that the development is not yet perfected, and conse- 
quently it does not even occur to you to associate disease with the 
parts ; but this tooth, only a single cusp of which is through the 
gum, may have caries extending into its pulp-cavity, or may be the 
seat of the most aggravated periodontitis. It is the common im- 
pression that wisdom teeth decay early ; that they are not a sub- 
stantial class of teeth. The fact is that four-fifths of the wisdom 
teeth which decay so early have been destroyed by this operculum 
of gum. The explanation is very evident. The decomposing epi- 
thelial scales, and other debris of the mouth, combine in the acidity 
engendered of their disintegration to irritate the bony structure of 
the tooth, thus quickly destroying its integrity. I am sure that I 
have seen more than a thousand cases illustrative of this fact ; and 
if any practitioner will take the trouble to dissect off this fleshy lid 
— the proper treatment, by the way — and examine with a delicate 
probe the sulci of such teeth, in nine cases out of twelve he will find 
caries. 

Such a lesion will at once be recognized to have important second- 
ary relations. For example, I have myself been consulted time and 
again by persons who have been sufferers for a considerable period 
from what has been pronounced and treated as neuralgia. Their 
teeth had not escaped observation, but had been examined and pro- 
nounced sound. I have found in such mouths not unfrequently this 
operculum of gum overlying the wisdom tooth. This I have dis- 
sected off, exposing compound caries. I have extracted such teeth, 
and the patients have been instantly relieved of their neuro-odon- 
talgia. 

Again; these fleshy cups, catching and holding, in contact with the 
soft parts, insoluble particles, as often found mixed with the food, 



THE TEETH AND THEIR DISEASES. 203 

will provoke periostitis, or even ostitis of the angle and ramus of 
the jaw. I have seen the most alarming inflammatory attacks thus 
provoked. The tooth in these cases, as I have somewhere else re- 
marked, will always be found responsive to the stroke of an instru- 
ment. Its periodonteum being inflamed, common sense would direct 
that it be at once extracted ; but such extraction is occasionally 
among the almost impossible things. A tooth so affected will not 
unfrequently have but a point erupted not larger than the head of a 
pin. In these cases the best thing that can be done is to extract 
the adjoining molar; this relieves the pressure on the ramus of the 
jaw, and gives room for the posterior tooth. It will commonly yield 
a cure. 

Trismus, depending on such lesions, is not unfrequently the only 
external evidence yielded of the existence of the condition. The jaw 
stiffens and relaxes, as an odontalgia will come and go. In such 
ephemera] cases it is not at all unlikely that the trismus is exclu- 
sively a nervous action, or reflected irritation, — slight and ephemeral 
local inflammatory action being the irritant. 

Wisdom teeth erupt from the seventeenth to the thirty-fifth year; 
commonly, however, at about the eighteenth year. 

Some years ago I treated a case of trismus, the history of which 
may be given as a very common one : 

The patient, David B., a farmer, after doing a hard day's work, 
and getting much overheated, threw himself down, just at early even- 
ing, in a cool outhouse, to rest. Here he fell asleep, not waking 
until near midnight. The next day he felt a soreness in the left su- 
perior alveolar arch, which soreness increased for two or three days ; 
after which it deserted the teeth and passed to the antrum. Then 
commenced a swelling in the integuments of the face, which advanced 
until it shut up completely the left eye. The jaws began to stiffen, 
and ended, after three or four days more, in complete immobility. 

I was called to the case, after the lock-jaw had existed nine weeks, 
the patient having barely been able to support life by putting his 
mouth into a basin filled with soup, and sucking the nutriment 
through his teeth. During this time he had been seen by seven 
different practitioners, no one of whom had seemed to appreciate his 
case, or, what perhaps is more probable, none of whom had been 
willing to assume the trouble of it. The patient had never told any 
of these gentlemen about the soreness first felt in his teeth, and no 
one of them had ever questioned him in this direction; his single 
complaint was of a great weight about his cheek. 



204 ORAL DISEASES AND SURGERY. ' 

The diagnosis of the case was, primarily, periodontitis; this in- 
flammation, by a double continuity of structure, had extended into 
the maxillary sinus, and to the integuments of the face. The inflam- 
mation of the antrum had been sufficiently severe to result in abscess ; 
abscess of the alveolo-dental membrane, and of the lining membrane 
of the cavity. The inflammation of the face had resulted in the 
exudation of lymph, which lymph in a state of coagulation was the 
cause of the trismus. 

A first effort was directed to getting into the antrum, which I felt 
well assured was filled with pus. This was done by prying out the 
second molar tooth with an elevator, pushing it into the mouth 
(from which, with some trouble, it was afterward gotten out); the 
extraction was followed by profuse discharge. The patient described 
the relief as being immense. 

I removed this particular tooth, not because it was more carious 
than its fellows, but because it was somewhat loose, and thus gave 
evidence of the diseased condition of its roots. Again, it is through 
the alveolus of the palatine fang of this tooth that we find our 
easiest and best road to the antrum ; in this case, as is seen, the 
fang communicated with the cavity. 

On the day succeeding the evacuation of the abscess, the patient 
expressed himself as entirely free from pain, his only trouble being 
the anchylosis, which had not, as yet, relaxed in the least. 

To the touch, all the parts about the articular extremity of the 
inferior maxilla seemed completely indurated. I hesitated to at- 
tempt the breaking up of the parts mechanically, fearing that thereby 
I might do injury to the important vessels which are associated with 
the head of this bone, — the internal carotid and internal maxillary 
arteries. The induration was of course extra-capsular, and of 
sufficient extent to have bound the jaw from the glenoid cavity to 
the anterior border of the masseter muscle ; passive motion was 
resorted to, but employed very gently. Blisters and sorbefacients 
were depended on. The case progressed very slowly, the patient 
having to come to my office every day for fifteen days ; at the end 
of this time, but after removing other diseased teeth from his mouth, 
he was dismissed cured. 

When one is called to a case of trismus of any standing, the 
anchylosis being the result of inflammatory action, question may 
arise as to the propriety of mechanically breaking up the adhesions. 
The condyloid extremity of the maxillary bone is assuredly not 
the stanchest part of the body, and there are anatomical relations 



THE TEETH AND THEIR DISEASES. 205 

which it would not be at all pleasant to disturb: these things are 
for the surgeon to decide upon. So far as I, individually, am con- 
cerned, I now use mechanical force in all cases that come under my 
care, premising of course that the case is one where, from inflam- 
mation, the trismus depends on effused lymph. I am willing to run 
the risk for the great and immediate good yielded ; some considera- 
ble experience in this direction assuring me that such risk is materi- 
ally influenced by the manipulations. Of course I do not mean to 
recommend that attempt should be made to open the mouth to its 
greatest capacity with a single turn of the lever employed, although 
there are cases where such practice would be very commendable. I 
have so opened the mouth many a time, but not in cases of long 
standing. Generally, the force should be applied with gentleness, 
gain a little one day, and a little the next ; it takes but a very short 
time to open a mouth in this way ; besides, if your force is applied 
with such judgment as not to provoke vascular action, you will arouse 
to co-operation the absorbent system, the excitement acting -as a 
stimulus to it, and it will be found to do its part vigorously. 

A person will not unfrequently be attacked with trismus after the 
dental operation of inserting a pivot tooth. Here the lesion is more 
than likely inflammatory in character, and the treatment is to be 
directed accordingly ; the root of the tooth is in a state of periodon- 
titis. Cases of pure tetanus, however, have had origin in such an 
operation. Where the lesion is inflammation, the parts are sore, and 
tender to the touch. 

A person will sometimes be attacked with trismus after the plug- 
ging of a tooth with metal ; the attack comes on suddenly ; it is a 
reflex nervous action, and is always to be esteemed of dangerous 
import. The conducting facility of the metal irritates the nerve 
periphery in the pulp ; this irritation is referred to the Gasserian 
ganglion, and thence reflected to the muscles of mastication. To 
prove the existence of this lesion, direct the patient to hold cold 
water in contact with the tooth. 

To treat a case of this kind, remove the metal ; when the irrita- 
tion has subsided, be sure that before refilling, anon-conducting sub- 
stance shall be placed between the plug and the floor of the cavity ; 
or, because of the thinness of the bony septum, it may be desirable 
to destroy the pulp. 

Spasmodic trismus, very persistent, may result from the employ- 
ment of two different metals in the operation of tooth-plugging; 
galvanic action is the consequence, and the nerve is subjected to a 



206 ORAL DISEASES AND SURGERY. 

most harassing irritation. To test for this trouble, increase the 
action by holding silver and zinc against the plug. This test, how- 
ever, will irritate any super-sensitive pulp into a state of excitement, 
and is an admirable search-warrant for obscure lesions of this organ. 
The treatment consists of course in the removal of the plug, and 
the medication, if required, of the irritated pulp. 

So I might extend over many pages the consideration of dental 
lesions in connection with trismus. I have, however, written 
enough, I presume, to direct a proper attention to the subject. 

To recapitulate: It is suggested that many of the cases of so- 
called idiopathic or obscure trismus will be found to depend on con- 
ditions associated with the dental arch. 

That to insure permanent relief, the treatment must include the 
primary lesion. 

That such primary lesions as are described in the chapter on 
"Anomalies" are always distinguishable. 

That where it is desirable to extract an offending wisdom tooth, 
and such extraction seems too difficult to attempt, the removal of 
the tooth immediately anterior to it will not unfrequently be found 
to meet the indications. 

That the immobility of the jaw, where acute inflammatory action 
exists, is to be treated on general antiphlogistic or phlogistic princi- 
ples, according as it seems probable or improbable that the inflam- 
mation may be resolved. 

That when the acute action has passed, adhesions are to be 
broken up by mechanical force carefully applied. 

That mechanico-dental lesions are not to be overlooked, but are to 
be searched for, and discovered secundum artem. 

Trismus Traumaticus. — This is that anchylosis, true or false, 
intra- or extra-articular, dependent on local injury received. Of such 
injuries we have, of course, a great variety. Blows inducing inflam- 
mation are among the common causes ; a not infrequent cause, and 
one difficult to be combated, resides in severe burns; sloughs from 
the undue use of the mercurials, as exhibited in gangrena oris, are to 
be enumerated ; in short, we might instance any condition in which 
the locked-jaw depends on conditions of a local signification attended 
with solutions or irregularities in the continuity of the structures. 
A case just dismissed in my own practice, in the person of a boy 
twelve years of age, had the anchylosis dependent on false articula- 
tion, the result of injury done the glenoid fossa three years before 



THE TEETH AND THEIR DISEASES. 



207 



by a blow upon the chin. The force of this blow being carried to 
the joint, a chronic inflammation had resulted in a filling up of the 
cavity on a level with the articular eminence. While in this peculiar 
situation, a species of irregular cavity had formed, which partially 
accommodated the condyle, compelling, however, dislocation when- 
ever the jaw was forced open beyond a certain point. In this case 
a fair cure was obtained by a tri-weekly manipulation of the bone, 
resulting, as I infer, in a better-adapted fossa through absorption. 
To procure such motion as seemed demanded, frequent luxations 
resulted, — causing at first not unfrequently much trouble in the re- 
duction. This patient has been advised to watch any tendency to 
contraction which may appear, and to keep it counterbalanced by 
rolling corks between his teeth, — an excellent means, by the way, 
where the expense of instruments prevents their purchase. 

The use of common bottle-corks as a means of overcoming false 
anchylosis I have employed for some time with the most satisfactory 
success. Beginning an operation with one of a diameter to be 
readily introduced, increasing sizes are to be rolled, one after the 
other, between the teeth, into its place. Timid children will permit 
the use of corks, who entirely resist the screw. 

At a late clinic of the University, a young man presented himself 
with the lower jaw so fixed that only by pro- 
foundly etherizing him was it possible to pass 
the blade of a common table-knife between his 
teeth. This condition, which had existed for 
two years, had resulted from a blow received 
upon the cheek involving in an inflammatory 
fixedness the masseter muscle. This case was 
treated, first, by subcutaneous section of the 
muscle, followed by the daily use of the screw. 
Through the use of this instrument there is no 
doubt of his being kept comfortable. He is 
directed to employ it daily, and never to allow 
the jaws to deny the introduction of two fingers. 
Without doubt, it will be found that eventually 
such modification of the contracted muscle will 
result that a fair cure may reasonably be anti- 
cipated. The section of the muscle in this case 
had of course but the meaning of affording the 
use of the second and true means of cure, namely, the daily stretch 
ing of the part. 



Fig. 56. 




208 



ORAL DISEASES AND SURGERY. 



Fig. 56 represents the instrument employed in the stretching pro- 
cess, and which has been furnished the patient for daily use: it is 
one devised or modified by the ingenious cutler to the University 
clinic, Mr. Kolbe, and surpasses any other form with which I have 
acquaintance : by simply turning the handle, the blades, as seen in 
the drawing, are gradually separated. The power residing in this 
instrument is sufficiently great to break up any anchylosis, true or 
false, I have ever seen: any jaw could be broken with it. A neces- 
sary addition, however, to the instrument, as now constructed, is 
felt to be required in the handle being made of metal rather than of 
wood, with the further addition of a transverse bar to afford a more 
convenient application of the force. I feel that I cannot too warmly 
commend this instrument as the very best now in use ; it will fulfill 
the requirements of any case to which such application of force is 
indicated, while the most careless patient may be intrusted to use it 
on his own jaws. 

Cases of false anchylosis will most frequently be found extra- 
rather than intra-articular ; or where the condition has existed for a 
long time, say for a year, then it is reasonably to be inferred that 
the two conditions are combined, that is, that that portion of the 
articular cavity which is not used has been modified by nutritional 
changes. Wherever, however, the lesion of a false anchylosis is 

situated, the philosoph}^ of its re- 
lief consists in the practice of pas- 
sive motion, — it is really only another 
expression of the mode of cure of 
urethral stricture : operation may be 
necessitated, but it is only to be prac- 
ticed in cases of urgent necessity. 

Besides the instrument commended, 
various others have been devised for 
the purpose of passive motion. Figs. 
57 and 58 show two other forms of 
such instruments. Fig. 57 is that 
known as the wedge of Scultetus. 
Fig. 58 is a modification, as is seen, 
of such instrument: neither of these 
deserves mention as compared with 
the instrument of Mr. Kolbe. 
In sections of the country where the mercurials are freely used, 
anchylosis from sloughing is not uncommon ; it is frequently found in 



Fig. 57. 



Fig. 58. 




THE TEETH AND THEIR DISEASES. 209 

these cases that the mucous aspect of the cheek has been converted 
into a dense unyielding fibro-cellular cicatrix, which resists all attempts 
on the part of the depressor muscles to antagonize it. In cases of 
this kind, instrumental aid is found most applicable, and, if properly 
and judiciously persisted in, will eventuate in satisfactory relief. 
Another local cause of anchylosis is found in bridges of bone asso- 
ciating neighboring parts, commonly the edges of the glenoid cavity 
with the neck of the lower jaw, or it may be that the relation is 
between the two maxillary bones. These bridges are not unfre- 
quently to be broken and their absorption secured through dilata- 
tion conjoined with passive motion and the use of sorbefacients. 
In no cases, however, is it more desirable to guard against inflam- 
matory results, and therefore such procedure is to be conducted with 
the same care as is felt to be necessary in breaking up anchylosis in 
the knee- or elbow-joints; a principle being, to make haste slowly: 
fracture of the neck may readily attend rough manipulation. 
Should such an accident occur, the desirability of making a false 
joint may have consideration : if a diagnosis exhibits complete 
fixedness of the head of the bone by a bony relation, then nothing 
better might be attempted than the creation of such false joint, union 
being prevented by passive motion, and inflammation combated 
through the agency of antiphlogistics, local and general, as might 
seem demanded. 

Cases occur where the only possible prospect of relief is found 
in the production of such a false joint by operation particularly di- 
rected to that end. Such mode of procedure suggests itself on 
review of the famous operation made many years back on the femur 
of a sailor, by Dr. J. Rhea Barton, in which a flexed limb was 
restored to usefulness by the removal of a Y-shaped wedge, thus 
allowing the leg to be extended. Both Rizzoli and Esmarch, acting 
on such principle, have been able to report satisfactory results. 
The operation as practiced by the first-named of these gentlemen 
consists in simply dividing the jaw by a delicate saw — the chain 
saw may be employed — in front of the lesion. Esmarch removes a 
Y-shaped wedge, the base being below, such passive motive being 
at once exercised as shall prevent union of the separated parts. 
Practicing either of these operations, the surgeon will become sat- 
isfied that they are only to be resorted to in the absolutely compul- 
sory cases. 

A case illustrative of the practice of Rizzoli is thus recorded : 
"At the time of admission of patient into hospital the left cheek 

14 



210 ORAL DISEASES AND SURGERY. 

was more depressed than that of the opposite side, and an explora- 
tion being made along the horizontal ramus of the jaw, the fact was 
established of the loss of osseous substance near the posterior angle 
of the jaw. The finger, when introduced inside the cheek, was also 
stopped by strong adhesions of cicatricial tissue, and the teeth were 
to be found in their alveoli, all except the two upper incisors, the ab- 
sence of which allowed of the introduction of some liquid nutriment. 

" The patient being sweated, and her head supported against the 
breast of an assistant, while another drew down the lower jaw, the 
operator made an incision in the cul-de-sac which united the lip and 
gum of that side, exactly at the space which corresponds to the 
second and third molars ; this incision divided not only the mucous 
membrane, but also the subjacent soft parts, so as to lay bare the 
lower border of the jaw; by this wound was then introduced the 
straight and blunt branch of the bone forceps, which embraced the 
internal border of the jaw, so that the cutting edge of the instru- 
ment was easily placed on the outside. A slight force only was 
necessarily required to completely divide the maxilla at one stroke, 
and thus restore to the jaw the motion which had been lost for 
eight years. The operation is alluded to as not being interrupted 
by any complications, either during or after its performance. The 
patient, a girl, is reported as being quite cured, able to separate her 
jaws widely ; to chew her food, to eat, drink, laugh, and speak, as 
in her normal state." 

A case of bony anchylosis presented in the clinic of the Pennsyl- 
vania Hospital, operated on by Dr. T. Gr. Morton, has the following 
history. It serves excellently well as a type of practice in its 
direction. 

"Charles H. Robinson," says Dr. Morton, "aged eight years, 
was brought to me in October, 1869, from Tallahassee, Florida, with 
an anchylosed condition of the jaws. In 1865 the child had been 
mercurialized for a long-continued bilious remittent fever; following 
this, very serious and extensive ulceration of the mucous membrane 
of the mouth resulted, and a slough on the left side of the face 
opened a communication through the cheek at a point corresponding 
with the second molar tooth, and which involved the parotid duct, 
through which for a considerable period saliva freely flowed ; an 
abscess behind the ear also developed, which discharged for a long 
time. The health of the child was very seriously impaired, and there 
was almost an entire arrest of bodily development. With the closure 
and final cicatrization of the parotid fistule and the healing of the 



THE TEETH AND THEIR DISEASES. 211 

ulceration of the mouth, permanent bony closure of the jaws followed, 
and for nearly five years the child had been fed entirely upon liquid 
food. On examination, I found the boy irritable, puny, and quite feeble. 
The spleen was greatly enlarged and quite hard ; complete osseous 
anchylosis formed the bond of union between the upper and lower 
jaws near the ramus on the left side, corresponding apparently to 
the seat of the original slough of the soft parts. The cicatrix was 
here firmly attached. On the right side of the mouth there was no 
attachment of bone and soft parts; the finger or probe could be 
readily insinuated between the alveoli and the cheek; the teeth 
were very brittle, irregularly notched, — and many had crumbled off, 
leaving numerous openings through which the child received nour- 
ishment. Generous liquid diet and the comp. syr. of the phos- 
phates were prescribed. 

"Oct. 6. — Admitted the boy as a private patient into the Pennsyl- 
vania Hospital. 

" Oct. 8. — After etherization, an attempt was made to force the 
jaws asunder with a dilator, but the teeth were so friable that this 
was abandoned. A curved incision was then made through the 
cheek to the angle of the mouth on the left side, and the flaps were 
dissected up. This exposed a bony bridge, extending from the upper 
to lower maxilla, about an inch in breadth and an inch and a half 
in length and of considerable thickness and extreme density. There 
was apparently no articular trouble. Cutting forceps made but 
little impression on the deposit, and the bridge was then removed 
by the saw. After the removal of this, the dilator was introduced 
and the jaws separated one and six-eighths of an inch. The external 
wound was united by silver sutures, and healed kindly ; extreme 
dilatation was kept up by plugs of wood for several days. The 
lad's general health continued to improve, and he was able to mas- 
ticate his food quite well, which was a source of great pleasure, not 
having tasted solid food for so long a time. Recovery was rapid, 
although prostrated from loss of blood at the operation ; yet he 
improved daily, and was discharged November 6, 1869, cured. One 
year afterwards he had good motion in his jaws. I have not since 
heard of his state of health." 

In such conditions of anchylosis as depend strictly upon cicatrices, 
the propriety is always to be considered of a plastic operation, which, 
removing the deformed tissue, shall replace it with that which is 
normal, secured from some convenient part in the immediate neigh- 
borhood. If the cicatrix to be replaced be small, adjoining portions 



212 ORAL DISEASES AND SURGERY. 

of the cbeek may furnish the required material; if, on the contrary, 
it be large, the neck will have to be depended on, or it may seem pre- 
ferable to employ the Italian method of taking a flap from the arm. 
The principle of the operation consists in mapping out on the part 
from which the flap is to be made such extent and shape of surface 
as shall replace that designed to be removed. The cicatrix being 
dissected out, and all bleeding checked, the flap as marked is raised, 
leaving it attached alone by its pedicle ; and when hemorrhage in 
this also has been controlled, and the surfaces begin to glaze, it is 
carefully to be turned on the pedicle into its new position, and, being 
fixed by stitches, is to receive the attention required by wounds in 
general. The space left by the removal of the flap is to be drawn 
together by stitches, adhesive strips, or other convenient means. 
Before undertaking a plastic operation, however, nothing is more 
necessary than to possess an appreciation of the reparative and 
nutritional powers of the patient. To operate on a person in a 
typhoid state, or on one the plasticity of whose blood is destroyed 
by the influences of syphilis, scrofulosis, scorbutus, or mercurializa- 
tion, would be simply to court failure. 

" Many cases of the disease atrasia oris, or closure of the mouth, 
are reported as presenting themselves to the notice of those attend- 
ing the medical charities of Calcutta. It would appear that there 
are here two very common forms of this disease : one in which the 
mucous membrane covering the front of the ramus of the lower jaw 
has been inflamed, and, subsequently contracting, causes closure of 
the teeth, without narrowing, to any considerable degree, the opening 
of the lips. If the history of these cases be traced, it will be found 
that they have generally resulted from the cutting of the last molar 
or wisdom tooth having caused the gum to inflame. The other 
kind of closure results from the indiscriminate and excessive use of 
mercury by native practitioners. The ulceration of the mucous 
membrane lining the gums and cheeks succeeds to the ptyalism so 
produced, and, on the inflammation subsiding, the opposed ulcerated 
surfaces unite and cause the jaws to be closed, and the opening of 
the mouth to be contracted. Both Dr. Fayrer and Dr. Partridge, 
surgeons to the charities, are accustomed to remedy the first accident 
in the same manner, by dividing the firm contracted band of mucous 
membrane with a knife (one of the tenotomy knives generally being 
found to be most convenient), and then forcing open the jaw by an 
extending trivalve speculum. With a little attention to dressing, this 
plan generally succeeds. In the other species of atrasia oris a similar 
plan was at first adopted. The adhesions were divided by a narrow 



THE TEETH AND THEIR DISEASES. 213 

knife, the jaws forced open by the speculum, if necessary, and lint 
dipped in oil was pushed in to separate the recently-cut surfaces. 
But the disease treated by this way alone had so great a tendency 
to relapse, that in a recent case Dr. Fayrer, in addition to the above, 
divided the skin at the angles of the mouth in a direction downward 
and outward ; and though at first this occasioned a most lachrymose 
expression to the man's countenance, it ultimately perfectly suc- 
ceeded, and he left the hospital cured." 

" Professor Reina has had occasion to observe four cases of a new 
form of morbid closure of the mouth, due, not to anchylosis of the 
articulation of the jaw, but to hypertrophic thickening and indura- 
tion of the membranous muscular tissues of one or both cheeks. 
Syphilis, scrofula, or the irregular and violent extraction of a molar 
tooth, were the causes of this alteration, and the closure led to much 
difficulty of respiration and speaking, and interposed an obstacle to 
the introduction of solid food into the mouth, from which resulted 
the various consequences of insufficient nutrition. 

" To remedy this deformity, Professor Reina divided, by means 
of a bistoury, the hypertrophied tissues, repeating the incisions 
whenever they became necessary, and incising transversely the mu- 
cous membrane, from the angle of the jaw to the commissure of the 
lips. The buccinator and orbicularis oris were entirely divided ; it 
became necessary, also, more than once to divide the anterior pillar 
of the velum palati and the glosso-staphvlinus muscle, and in such 
case the operator was, moreover, obliged to relax the corresponding 
side of the tongue, which adhered to the interior of the gum. The 
arterial hemorrhage was combated successfully by compression. 

"With the help of conical pieces of cork introduced between the 
teeth, the abduction of the jaws was facilitated, at the same time 
that an obstacle was interposed to the union of the divided parts. 
Finally, the diatheses were combated by general treatment, mercurial 
or iodized, according to the special indications." 

Concluding this consideration of fixedness in the jaw, a resume of 
Ihe subject exhibits as causes of the condition, — 

1st. Spasm ; the treatment being of constitutional consideration. 

2d. Anchylosis by muscular induration ; the treatment being by 
local medicaments, combined with the employment of the dilator. 

3d. Osseous anchylosis ; the treatment being the breaking up 
by section or otherwise, if permissible, of the bony bridges. 

4th. Cicatricial anchylosis ; the treatment being by dilatation 
and by plastic operations. 



CHAPTER X. 



THE TEETH AND THEIR DISEASES. 



CAKIES. 

Caries of the teeth being a disease so destructive to comfort and 
to health, and withal so common as to possess its illustration in 
almost every human mouth, makes the subject felt as one claiming 
earnest investigation and attention. 

Caries of a tooth, most simply expressed, is corrosion of its sub- 
stance : the disease may occur on any part of the surface of the 
crown or even the root, but as a rule is found to originate on parts 
possessed of the least self-cleansing characteristics. Thus, it is 
most common to the sulci on the grinding faces of the molars and 
bicuspidati, to the posterior depressions met with so frequently in 
the superior incisor teeth, and to the proximal faces of the teeth 
generally. 

Caries is a disease of chemico-vital relation, and is unfortunately 
most markedly of congenital association and predisposition : indeed, 
so true is this, that it may be prognosed that the offspring of parents 
afflicted in this way will be in like manner afflicted, and that, on the 
other hand, the children of parents possessing good teeth will be in 
like manner favored. So constant is this analogy in the teeth of 
parents and child, that in most instances it extends to the very 
shape and arrangement of the organs, deformity insuring deformity, 
and regularity regularity. One parent alone may influence for good 
or evil. 

Hereditary dental caries finds its explanation in likeness of condi- 
tion, this being of local or constitutional signification, or more com- 
monly a conjoining of these ; sUch teeth being not only imperfect 
in development in one or more directions, — in shape, in deficiency of 
enamel-covering, in non-calcification as exhibited in the existence 
of interglobular spaces, in position, in tubular circulation, in nerve 
endowment, — but in an equal number of cases in lack of physiologi- 
cal harmony, either in surrounding secretions or in the offices of 
(214) 



THE TEETH AND THEIR DISEASES. 215 

nutrition : any or all of these may be the conditions, as, indeed, re- 
sultant from them are all cases of caries. 
Health in the dental organism depends : 

1. On circumstances associated with the original formation. 

2. On the shape of the teeth, their relation to each other, and 
their self-cleansing features. 

3. Constitutional conditions. 

4. Character of agents in contact with the teeth. 

5. The absence of mechanical destructives, as salivary calculus, 
the bands of artificial dentures, etc. 

6. Accidental influences. 

Condition 1. On circumstances associated with the original for- 
mation. 

To appreciate the reasons explaining the inability on the part of 
certain dentures to fulfill the intentions of their creation, we are 
compelled to consider, not unfrequently, influences and associations 
apparently far remote from them. That the student may be made 
familiar with the principles involved, without which, indeed, he might 
not otherwise than mechanically treat carious teeth, it is proposed to 
invite his attention to that study and understanding of the subject 
which practice will demonstrate as the exhibition of it in a clinical 
fullness. 

It is to be assumed, as a premise, that like begets like ; therefore 
may unhealthy parents not fail to impress upon their offspring that 
which is of their own constitution. Of these impressions, some we 
find ourselves able readily to appreciate ; others are obscure. As 
examples, we may refer to cachexias, evident enough in their indi- 
viduality as exhibited over the general system ; again, to a transmis- 
sion which illustrates itself alone in the direction of the teeth, the 
individual at large being otherwise healthy. These two type con- 
ditions exhibit themselves to every observer. 

Of the cachexias pertaining markedly to the matter of our investi- 
gation, we have three, — scrofulosis, rickets, syphilis ; cachexias so 
widely associated with asthenic conditions, so adverse to the healthy 
performance of the nutritional functions, that without an under- 
standing of their expressions one might not hope to antidote their 
multitudinous sequelae. Because, therefore, of the marked impor- 
tance of the cachexias, viewed in hereditary association, the student 
is invited to complete, by reference to the proper works, the epitome 
here presented. 



216 ORAL DISEASES AND SURGERY. 



DISTINCTIVE FEATURES IN" TYPICAL CASES OF EACH CON- 
DITION. 

Scrofulosis. — Temperament lymphatic ; abdomen tumid ; com- 
plexion flat and pasty; lips and ala3 tumid ; saliva stringy; breath 
insipid and offensive ; mucous membrane markedly deficient in cir- 
culating activity, and much disposed to degenerative inflammatory 
action; lymphatics enlarged and prominent, especially those of the 
cervical and mesenteric regions, with great disposition to suppura- 
tion ; bones very loose and spongy in their areolar tissue, often fatty, 
breaking down on slight provocation into caries and necrosis ; 
teeth, alike with the bones, deficient in inorganic material, loose in 
the character of the intertubular structure, more or less deficient in 
the integrity of the enamel cap ; the animal matter very susceptible 
to the irritating influences of the unduly alkaline oral fluid; the pulp 
pabulum cacoplastic to an extent which almost completely stagnates 
the tubular circulation, thus antagonizing nutrition ; conditions of 
dental health adverse without and within. 

Rickets. — Physical force deficient ; habits sluggish ; mentality 
small, with precocity ; large head, more commonly broad than 
long; abdomen prominent and heavy; leanness ; general debility, 
with indigestion; puffiness of the extremities; skin muddy; thin- 
ning of cranial bones, together with a plastic thickening of other 
flat bones and enlargement of the extremities of the long bones ; 
tendency to aplastic infiltrations of the viscera ; the teeth late in 
erupting, slightly attached to their alveoli, non-resistive of external 
offenses, which act easily to a chemical disintegration of them, and 
most apt by slight causes to be pushed from their sockets. 

Syphilis and Mercuric- Syphilis. — Stagnant complexion ; lean- 
ness; atony of the skin and muscles; susceptibility to skin-affec- 
tions; poor and scanty hair ; interstitial keratitis, with interlaminal 
corneal lymph effusions; stomatitis; tendency to iritis; the teeth 
more or less notched on their cutting edges, with pittings of the 
enamel ; mucous membrane passively congested and easily breaking 
down into ulcers, which ulcers have pasty bottoms ; seroplastic 
effusions into the submucous Schneiderian tissue, interfering with 
respiration, inducing in the patient constant sniveling ; eruptions on 
the skin of a coppery-red color; periosteal indurations, with sub- 
periosteal aplastic exudates ; suppuration of organs, as the liver, 



THE TEETH AND THEIR DISEASES. 217 

thymus, testes; caries and necrosis of bones, particularly the turbi- 
nated and the maxillae, and of the teeth. 

Scrofulosis — Scrofula. — This is a constitutional condition 
having its recognition in the cacoplastic conditions common to it 
and begotten of it, the manifestations of malnutrition being most 
frequently met with in the skin, mucous membrane, hip- and knee- 
joints, and in the lymphatic glands, which latter, in their suppuration, 
present most markedly the feature of a cheesy degeneration. 

Scrofula is commonly an inherited cachexia, but may, through 
depressing circumstances, be engrafted into any constitution. Bad 
and ill-nourishing or insufficient food, continued exposure to impure 
air, intemperance, excessive venery, mental anxiety, the effects of 
severe courses of medication, secondary effects of poisons, — these 
and similar causes may induce the cachexia. 

A marked scrofulous hereditary transmission has its expression in 
the type case given, but from this it is to be esteemed as shading 
into the greatest variety of aspect. Two primal expressions are clearly 
to be recognized. These are the fair and the dark; to be again sub- 
divided into the fine and the coarse. The fine is the disease as exist- 
ing and exhibiting itself in the sanguine temperament ; the coarse is 
the typical case, as exhibited in the sluggish lymphatic. It is well 
just here for the reader studying this disease from the standpoint of 
dental caries to exclude the fair variety, and to place it under the 
head of Tuberculosis, — a distinction in the conditions which one 
most practically recognizes as relation with the health of the teeth 
and general digestive apparatus is concerned ; the typical form being 
markedly provocative of dental disease ; the fair variety exhibiting 
its manifestations in the viscera, and most particularly by deposits 
in the lungs, leaving the teeth quite exempt from any impression. 
Hence in persons affected with phthisis it is not uncommon to find 
the most beautiful and perfect dentures. It is to be remembered, 
however, we are writing of predispositions, and not of manifestations 
from active or recent conditions ; of impressions made on the teeth 
during the stage of formation and development, and not of impressions 
made by the acquired disease on teeth whose period of growth might 
have been associated with such vigorous and health-yielding life 
that the result is not to be easily overcome. 

Scrofulosis of the lymphatic type expresses that condition of a 
system in which morbid action results on the slightest provocation. 
Every part seems lax and incapable of self-sustenance. The slightest 



218 ORAL DISEASES AND SURGERY. 

injury produces inflammatory action, yet of a grade requiring for 
its control stimulation rather than depression. In a word, it is a 
condition in which the vitalizing principle has no proper proportion- 
able correspondence with the matter of the body. Hence the char- 
acteristic sluggishness, — the body is only half living, and was so 
born, — the parents before it lacking that fullness of force neces- 
sary to the vitalization of the offspring. No single tissue has been 
harmoniously constructed, the production being to an extent an 
abortion. 

Perhaps the student will possess himself of a clearer conception 
of scrofulosis if we deny to it the name of a disease, and associate 
it alone with the idea of cachexia ; and this, if we exclude from the 
relation tuberculosis, with its peculiar deposit, one inflicts no vio- 
lence in doing. It is thus, from clinical observation, I have been 
led for myself to consider it, and such understanding seems best to 
conduce to antagonizing its relations. We view the house as one 
ill built and of poor materials, and do what we can to remedy the 
deficiency. It is a condition in which attempts at specific treatment 
have no signification : there is no special condition to combat. With 
tuberculosis, the case will most likely prove to be different. 

In conjoining the axioms that "excitement must terminate in 
exhaustion," and that "from nothing may nothing come," we may, 
I think, find the precedents and conditions of scrofulosis. In an ani- 
mal body are so much matter and so much vitality. As the vis vitse 
may be abstracted from one part to minister to the excitation of other 
parts, so necessarily must both come to suffer ; the first from an over- 
stimulation which begets hypertrophic degenerations, morbid plastic 
formations capable of organization, thus compelling alteration in 
physiological expression ; the second, from exhaustion through the 
absence of its correlating force, thus denying the changes neces- 
sary to the fulfillment of functional life, — breeding, of necessity, 
debility. 

Over-stimulation, with its consequent exhaustion, finds exam- 
ples in the intemperate, the venal, and the gluttonous. Children 
begotten of these in the days of their exhaustion, are apt to be 
possessed of evidences of the vices. 

Exhaustion, on the other hand, is found a primary condition, being 
a result of exposure to influences debilitating in themselves ; as, for 
example, to poisons, deprivation of proper food, insufficiency of 
clothing, to lack of cleanliness, being ill housed, unhealthy employ- 
ment, continuous subjection to mental disquietude or oppression, 



THE TEETH AND THEIR DISEASES. 219 

excessive secretions and discharges, deprivation of light and sun- 
shine, etc. We are to assume that the disease we study is not a 
materia peccans in the blood, but, as Billroth expresses it, " a debility 
of the organization." Dr. C. J. B. Williams, while admitting no dis- 
tinction between scrofulosis and tuberculosis, yet describes the 
condition as " a degradation of the nutritive material from which old 
textures are renewed and new ones formed, in that in its origin it 
differs from the normal plasma or coagulable lymph, not in kind, but 
in degree of vitality and capacity of organization." 

What cacoplastic lymph is, we appreciate. What tubercle is, we 
do not know; the highest authorities, in such direction, are still at 
issue concerning not only the origin, but even the nature, of tubercle. 
Whether, therefore, tubercle is or is not an expression of struma, we 
are, in our present connection, not concerned to discuss. Proto- 
plasm, lymph, is the basal nutritive agent; plasma is not self-creat- 
ing or of itself, but a product of vital force acting on materials taken 
for the nourishment of the body. That organs be normal, pro- 
toplasm must be normal. The diseased protoplasm of degraded 
parents — more particularly, perhaps, that of the mother — may not 
afford that nourishment which is the proper life of a child; on the 
contrary, it associates its own degradation with all with which it 
may come in association. 

Following such line of view, it will be recognized that we may not 
have any marked distinction between scrofulosis and the hereditary 
manifestations of syphilis, of the mercurial vice, or of other parental 
adynamic transmissions; and, therapeutically viewed, this premise 
we believe to be the proper one, — the principle of treatment being 
found the same, — this being tonic medication, and having no spe- 
cificity to which it is to be directed. If, however, special organs 
be specially affected, this would of necessity direct to them particu- 
lar attention, and the treatment, as the part affected is concerned, 
would, in local requirements, differ, — as, for example, whether we 
might have to combat caries of the bone or caries of the teeth ; the 
constitutional treatment may, however, only be the same, and from 
such aspect, what would be the cure of the one would necessarily 
tend to the same result in the other. Unfortunately, however, as 
the teeth are concerned, from the low grade of their vitality, and, 
consequently, the inactivity in their molecular changes, counter-im- 
pressions are long in being made ; therefore, in the constitutional 
caries of these organs, too much attention cannot be given to the 
local relations. The fluids of the mouth are, if adverse, to be neu- 



220 ORAL DISEASES AND SURGERY. 

tralized to the required non-antagonism. Cleanliness is to be par- 
ticularly insisted on, and all cavities are to be filled or filed away, as 
may seem indicated. 

Rachitis — Innutrio Ossium. — A constitutional disease, having its 
predisposition in hereditary transmission : characterized by non- 
solidification of the growing layers of bone, by the formation of 
medullary cavities in the older or more mature bones, thus render- 
ing the bony laminae thin and brittle (Yirchow), and by excess in the 
formation of phosphoric and lactic acids, with great excess of the 
earthy phosphates. 

It is not to be maintained that rickets is a constitutional disease, 
save in the sense of predisposition. Neither is it to be affirmed that 
it possesses a constancy of expression which allows of a common 
formulary for a description of its diagnostic signs ; on the contrary, 
the expressions vary from the most simple manifestations of a 
disturbed nutrition to a specific alteration in the bones, which renders 
them, from lack of inorganic constituents, incapable of performing 
their functions. Indeed, it is probable that degrees of rickets may 
quite frequently present themselves and yet be overlooked. While, 
as suggested by Hillier, the secondary diseases, such as bronchitis, 
collapse of the lungs, atrophy, measles, hooping-cough, or convul- 
sions, are recognized, the primary disease, which renders these sec- 
ondary conditions fatal, is quite ignored. 

As rachitis is congenital, or as it associates itself with the denti- 
tional periods, so are manifested the effects of the condition upon the 
health of the teeth, — these organs being delayed in their development, 
disposed to caries, and not unfrequently of such loose relation to their 
sockets from aplastic softening of the peridental tissue as to be dis- 
placed by slight force : the periodonteum, and also the pulp, may be 
affirmed to present evidences of the common amyloid degeneration 
as seen in the viscera, particularly in the liver and spleen. The 
delay in the cutting of the teeth is simply delay in development, 
the albuminoid pulp lacking organic force to secrete dentinal tissue; 
while, as is to be inferred, that which is made is of such imper- 
fect organization, so mottled with uncalcified spots, — interglobular 
spaces, — as to be rendered quite incapable of resisting that excess 
of lactic acid found in the secretions coming in«contact with it. 

History. — Rachitis is a disease having perhaps in all cases the 
association of hereditary predisposition, yet, like scrofulosis, exist- 



THE TEETH AND THEIR DISEASES. 221 

ing in such variety of aspects and in such states of modification as 
to make it not easy of recognition through any constant signs. 
These modifications are of a twofold nature. First, the character 
of the hereditary impression. Second, the associative surroundings 
and conditions of the patient. Sir William Jenner, whose lectures 
on the subject are worthy of all respect and attention, speaks of this 
disease as " without question the most common, the most important, 
and, in its effects, the most fatal of all that exclusively affect chil- 
dren." Hillier (Meigs and Pepper) presents a table showing the 
proportion borne by the number of cases of this disease to the total 
number of out-patients treated at the Hospital for Sick Children, 
London, from which calculation exhibits that of 128,656 children 
treated during thirteen years (1854-66) not less than 8419, or 6.5 
per cent., were rachitic; and in some years the proportion of such 
patients rose as high as 9 per cent. In London hospitals and in the 
other great hospitals gathering in the poverty and degradation of 
any large city, such percentage does not strike us as at all a matter 
for surprise. It must be recognized, however, as is to be inferred 
from home observation, that such statistics designate the disease as 
included in its diversified phases. 

The cachectic state preceding the osseous manifestations of rickets 
is not generally to be noticed at birth, but develops commonly during 
the process of the first dentition, seldom appearing at a later period 
than during the time of the active stages of the second. The incu- 
bation precedes, however, the manifestations of the cachexia, residing, 
as we incline to believe, in an original molecular impression : at least 
it is only thus that we find explanation of the organic impressions 
found in the structure of the deciduous dentine and enamel. 

The relation of rickets with scrofulosis is found in the pre-associa- 
tion of the two conditions. Thus, " Whatever tends to produce 
debility and anaemia in a mother, as too frequent pregnancies or 
prolonged lactation, renders it probable that her next-born children 
will be rickety." Jenner states "that it is very common for the 
first, or the two or three first-born children, to be free from any 
signs of rickets, and yet for every subsequent child to be rickety ;" 
which he explains by the fact "that among the poor the parents are 
generally worse fed, worse clothed, and worse lodged the larger the 
number of their children ; and among the rich and poor alike, the 
larger the number of children, the more has the constitutional 
strength of the mother been taxed, and the more likely is she to 
have lost in general power." (M. and P.) 



222 ORAL DISEASES AND SURGERY. 

Predisposition in a child maybe overbalanced by its prophylaxis. 
Thus, children of wealthy parents, even where the antecedents are 
very unfavorable, may escape the evident expressions of rickets as 
the result of hygienic antagonisms, just as adverse conditions are 
found to prove exciting causes to its development. It is indeed 
because the most characteristic expressions of this disease — namely, 
affections of the skeleton — are so influenced by outward circum- 
stances, that eminent observers have in some instances come to deny 
its existence among the better classes ; though this differs much from 
the statement of Jenner, who asserts that he has very often met with 
it among the children of the very wealthy. We think, however, 
that it is to be made a cardinal point that the disease is not neces- 
sarily to exhibit its osseous complication to have existence, and that 
its prodroma are as much the condition (in abstr^acto) as is the 
observable softening itself. 

The relation of rickets with hereditary syphilitic disease is 
affirmed by Yogel, who professes to base the deduction from wide 
clinical inquiry. Such relation is, however, denied by Sir William 
Jenner, the denial being founded mainly on the following facts : 
" The parent who infects his offspring (with syphilis) has usually- 
contracted the syphilis before marriage, and the children first begot- 
ten after infection are those who suffer (from inherited syphilis) ; 
while, as a rule, it is only the younger children of a family that 
suffer from rickets." Sir William Jenner is also doubtful as to the 
health of the father affecting the child, but throws the weight of his 
influence in that scale which attributes the disease to insufficient 
nutrition ; thus suggesting the inference of the direction in which 
lies its prophylaxis, and as well indorsing, without intention, the 
oneness of cachexia. Mr. Lonsdale expresses himself as having 
invariably found "that in all rickety children the parents have had 
little or no milk for their supply, and have been obliged to feed the 
children either partially or wholly with food other than the milk of 
the mother. The mothers observe that the children never grew 
properly from the first, and it is mainly the improper nature of the 
supplementary food given by hand which impairs the health of the 
child. The rearing of the children of the poor in London is thus 
described by Sir William Jenner: 

" For the first two or three days after birth their tender stomachs 
are deranged by brown sugar and butter, castor oil and dill-water, 
gruel and starch-water. As soon as the mother's milk flows, they 
are, when awake, kept constantly at the breast ; and well for them 



THE TEETH AND THEIR DISEASES. 223 

if they are not again and again castor-oiled and dill-watered, and 
even treated with mercurials. After the first month, bread and 
water sweetened with brown sugar is given several times a day, 
and during the night the child is, when not too soundly asleep, con- 
stantly at the breast. As soon as the little ill-used creature can sit 
erect on its mother's arm, it has, at parents' meal-time, 'a little of 
what we have,' — meat, potatoes, red herring, fried liver, bacon, pork, 
and even cheese and beer daily, and cakes, raw fruit, and trash of 
the most unwholesome quality as special treats, or as provocatives 
to eat, when its stomach rejects its ordinary diet. Then, instead 
of being weaned when from ten to twelve months old, the child is 
kept at the breast when the milk is worse than useless, to the injury 
of the mother's health, and to the damage of its after brothers and 
sisters, in the hope that thus keeping it at the breast may retard 
the next pregnancy." (Holmes.) 

According to M. Guerin, there will commonly be in rickets a 
period of at least six months before the practitioner may feel assured 
of the exact character of the case, or fairly distinguish it from other 
diseases to which the prodroma are common. 

The incubative stage is characterized by irritations of a gastro- 
intestinal character. The stools are irregular, being sometimes 
scanty, but more commonly profuse, marked by absence of bile, not 
unfrequently being of leaden color and most offensive in odor. Some- 
times, however, and this more particularly in the beginning, the 
discharges are greenish, of a serous or watery consistence, with a 
smell which has been compared to that of rotten meat. The child 
is found to run down as from a chronic diarrhoea. 

A marked symptom soon supervening, and one which is not un- 
frequently the first that suggests to the practitioner the peculiar 
nature of the disease, is profuse perspiration of the head. These 
perspirations weaken the child very rapidly, and, when in progress, 
the evidences of congestion are to be observed in all the neighboring 
vessels, — veins and arteries. 

Associated with this sweating, and more or less synchronous 
with it, is a general soreness of the body, the little patient in many 
cases lying motionless for hours, rather than endure the discomfort 
of moving. Such soreness has always more or less connected with it 
a desire on the part of the child to be cool, even in winter; such 
patients seeming most comfortable when lying entirely uncovered, — 
a fact sufficiently demonstrated in hospital wards. 



224 ORAL DISEASES AND SURGERY. 

The deformities of the head in rickets are thus distinguished by 
Sir "William Jenner:* 

1. By thickening of the bones. This is usually most perceptible 
just outside the sutures, the situation of the sutures being indicated 
by deep furrows. 

2. By the length of time the anterior fontanelle remains open. In 
the healthy child, it closes completely before the expiration of the 
second year. In the rickety child, it is often open at that period. 

3. By the relative length of the antero-posterior diameter of the 
head. 

4. By the height, squareness, and projection of the forehead. The 
first two of these peculiarities of the rickety head are the result of 
the affection of the bones ; the last two are chiefly due to disease of 
the cerebrum. 

The succeeding conditions are those which associate themselves 
with bone disease. 

The process of dentition (Holmes) is invariably arrested or de- 
layed ; and if the teeth are formed, they soon decay, or they early 
fall from their sockets, the incisors frequently being lost before the 
second molars of the first set have made their way through the 
gums. So important is the knowledge to be derived from the progress 
of dentition, that Sir William Jenner lays down the following rule 
of practice : 

" If a child pass over the ninth month without teeth, you should 
carefully inquire for the cause. It may be that an acute illness has 
retarded dentition. It may be (and this is infinitely the most 
common cause of late dentition) that the child is rickety. Fail not, 
then, when called to a child in whom the teeth are late in appearing, 
to look if it be rickety, for if you do fail to look for rickets, you will 
most likely attribute to the irritation of teething symptoms which 
are the consequences of the rickety diathesis, — the late dentition in 
rickets being in itself merely a symptom of the general disorder. 
The rickety deformities may be very trifling, and yet the teeth con- 
siderably retarded in their development." 

The inorganic constituents of bone — the earthy phosphates — are 
sometimes found in great excess in the urine, a case being recorded 
by Mr. Solly Avhere such excess was fourfold. It is perhaps, how- 
ever, as frequently the case that the deficiency in lime-salts results 

* Medical Times and Gazette, I860. See also Holmes's System of Surgery, 
vol. i. 



THE TEETH AND THEIB DISEASES. 225 

from non-ingress of these materials, without change in the egress; 
while a hypothesis founded on the observations of Marchand 
attributes the absence of the phosphates to their dissolution by lactic 
acid. This is effected, as inferred, by the lactic acid changing the 
carbonate and phosphate of lime into the soluble lactate, which in 
this state is capable of being taken up and carried from the system ; 
or, when not removed in this w r ay, it might be possible for the 
organic basis of bone to be dissolved by the inflammatory neoplasia 
with a breaking down of the chalky substance, whose molecules might 
either be dissolved or carried away. 

In rachitis, according to Virchow, the bones are histologically 
formed, except that the bone-cartilage has no chalky salts, — or, at 
least, little in proportion to their requirements. Billroth directs 
attention to the effect of the dyscrasia upon dentition. The treat- 
ment he regards as of that general nature which pertains to the 
building up of the health of the patient. As food, it may not be 
well to use too freely of bread, potatoes, mush, or flatulent vegeta- 
bles, but the child is to partake freely of meat, eggs, milk, and 
all nitrogenous diet. Billroth, in discussing the use of preparations 
of lime, expresses a doubt as to any benefit that may arise from their 
employment, deeming it not impossible that rachitis may be a disease 
of digestion in which such preparations may not be absorbed, — which 
view is indeed a common one among American physicians. 

A rachitic child should be daily bathed in salt water, lukewarm 
or cold, as seems most suitable ; the dress should be adapted to 
the season ; and daily exercise, active or passive, is to be taken in 
the sunlight and open air. The use of cod-liver oil has the recom- 
mendation universally both of European and American practitioners. 
Yogel asserts that rickets may be cured by the use of cod-liver oil 
alone. Rickety children tolerate the oil well, and are usually found 
to become fond of it. Iron and the vegetable tonics are almost 
always found useful ; while beer or wine in limited quantities, grad- 
uated to the age and condition of the patient, will sometimes be 
found to meet the indications most admirably. 

Syphilis. — Viewing the relations of this disease with the health 
of the teeth, we necessarily embrace, or, indeed, perhaps more fully 
treat of, the association of the mercurial poison than that of 
syphilis itself, inasmuch as the two are found so constant!} 7- combined 
that it may be esteemed a matter of some doubt if the single rela- 

15 



226 ORAL DISEASES AND SURGERY. 

tion is ever met with in the hereditary aspect. I use the term in 
the fullest sense of heredity, not embracing the cases in which a 
fcetus receives inoculation in passing over an unhealed vaginal 
chancre, or where the father, having incipient secondary manifesta- 
tions, extends such to the impregnating sperm. 

That the syphilitic poison impresses of itself the growing teeth 
is made evident by the very frequent imperfect development of these 
organs found in association with the disease, and which, outside the 
specificity, may not well be accounted for. I allude to the notching, 
the pitting, and the small size, — conditions which may fairly be 
presumed not to have special relation with the second of the poisons, 
inasmuch as this renders its expression in that general molecular 
depression which is seen in the lowered vitality of the parts at 
large, and which has just been considered under the head of scrofu- 
losis. 

The pittings in the enamel of the teeth, and the irregularities of 
the cutting faces, represent expressions believed to be found only 
in connection with hereditary syphilis, and which it seems proven 
may be transmitted to the third generation. These deformities are 
seen most generally in the second set alone ; the first are liable to 
early decay, but not so much to the malformations. The impres- 
sions are confined to the anterior six teeth, and vary from the most 
marked examples to scarcely perceptible irregularities of the cutting 
edges, or an occasional depression seen here and there upon the 
anterior face, or it may be the posterior, — most frequently, however, 
upon the anterior alone. Observations will be found to greatly vary 
concerning the existence of any constancy in phenomenal expres- 
sions of the teeth in this relation. 

The diagnostic signs and conditions of acquired syphilis, it is to 
be taken for granted, are known to the reader. With these we have 
nothing to do, inasmuch as the influences we consider are those 
impressed in utero. 

I think I will be borne out in the assumption that it is only in 
earliest infancy that syphilis expresses itself with that distinctness 
which, outside of the history, renders its diagnosis reliable ; and, 
further, that parents afflicted with the advanced tertiary stage of the 
disease do not transmit the disease with diagnostic individuality, but 
rather that in the term scrofulosis lies its expression, that the con- 
dition of the syphilides is the state in which the transmission retains 
specificity, — the tertiary stage expressing the exhaustion of the 
disease in the molecular degeneration induced of it, — and that when 



THE TEETH AND THEIR DISEASES. 221 

transmitted in such secondary stage, its continuous course in the 
child is apt to be the same as that in the parent. 

As a syphilitic impression has been made on the foetus with the 
condition of the parent or parents most closely allied to the first of 
the secondary manifestations, so will the_ child exhibit rashes, or the 
graver expressions of mucous inflammation. Thus, without per- 
haps proper attention to such data, it has become common to write 
of the confounding of the secondary with tertiary manifestations, — 
a confusion that does, however, without doubt, occasionally exist, 
owing to the general slighter resistive force of particular infants, 
just, indeed, as the same confounding of conditions is not unfre- 
quently met with in the adult. 

The expressions of the transmission of uncomplicated syphilis 
show themselves commonly by the third w T eek ; although instances 
enough occur where the child is born with such evidences ; or the 
little patient may live for a year without any sign of the disease ex- 
hibiting itself, — seldom longer, however. 

Hereditary syphilis differs of course from the acquired in having 
no primary stage. As in my own observation I have met with the 
condition, the most common manifestation is found in that morbid 
congestive state of the Schneiderian mucous membrane, which, 
as in a common cold, yields what the parents call snuffles, being 
universally attributed to the child's having a cold. Unfortunately, 
however, such colds do not tend to self-cure, but in very many 
instances, perhaps in a majority, produce changes in the nasal 
relations which result in a flatness of the bridge of the organ, bearing 
the sign throughout life, and which is justly to be esteemed as 
markedly diagnostic of the hereditary association. 

A child afflicted with this disease may, without doubt, be born 
plump and apparently vigorous ; but such vigor, as remarked by all 
observers, proves evanescent. After a few days, or weeks, or, it 
may be, months, the child will begin to emaciate, the skin wrinkles 
from absorption of the underlying fat, the face shows discolorations, 
and a peculiar expression of premature age comes on : this expres- 
sion of age is so marked and persistent that it will be found to 
characterize every child, young or old, afflicted with transmitted 
syphilis. I have this moment in my memory the faces of a number 
of little girls who are in the habit of occasionally presenting them- 
selves at my clinic, and, although the eldest is not over thirteen, 
they have, all, the demure expression of years quite in advance of 
them. Yet such expression, I remark, seems influenced by the stage of 



228 ORAL DISEASES AND SURGERY. - 

their affection, those afflicted with bone-troubles being usually older- 
looking (in proportion to their years) than others presenting alone 
the skin-manifestations. 

The appearance of pemphigus soon after birth, associated with 
the ordinary early symptoms, is deemed by experienced observers 
very diagnostic. Interstitial keratitis with inter-laminar lymph-effu- 
sions is associated alone with the hereditary form of syphilis, — iritis 
being an expression of the acquired form. In hereditary syphilis 
the manifestations are symmetrical; in the acquired form they are 
rarely so. The manifestations of the hereditary, form run one into 
the other; those of the acquired tend to remain distinct. 

From this necessarily limited discussion of the hereditary vices 
we pass to that aspect of the subject which considers the relation 
of developing teeth with nutritional instrumentalities. 

In viewing, from a systemic standpoint, the composition of the 
teeth, we have primarily to remark that the component parts are 
formed from and preserved by the chemico-vital relationship exist- 
ing between blood and parts to be nourished. We recognize, and 
know, that in the fluid which we denominate blood resides the 
element of nutrition, and that as this material is well or ill adapted 
to meet the requirements of the different tissues, so are these tissues 
found to be in varying states of health. We infer that blood, rich 
in the elements of tooth-structure, is capable of yielding good teeth, 
provided the process of assimilation resides to a proper extent in the 
part to be built up and nourished : so that the study of caries, from 
the constitutional standpoint, consists in looking at the condition 
of the blood and the amount of vital force residing in the teeth 
themselves. 

A tooth in its composition is made up of cementum, dentine, 
enamel, and pulp substance. Excluding the pulp substance, we 
find, with some variation, the relative proportions of organic and 
inorganic matter to be as follows : 

Cementum. Dentine. Enamel. 

Organic matter 29-27 28 70 3-59 

Inorganic matter 70-73 71 30 96-41 

The character of this inorganic material we find, by a more com- 
plete analysis, to be as follows : phosphate of lime, filiate of lime, 
carbonate of lime, phosphate of magnesia, salts. 

The composition of healthy blood yields the following analysis : 



THE TEETH AND THEIR DISEASES. 229 

Water 780 15 

Fibrin 2-10 

Albumen 65-09 

Coloring matter 13300 

Crystal Hzable fat 2-43 

Fluid nit 1 31 

Extractive matter 1 79 

Albumen, in combination with soda 1 26 

Chlorides of sodium and potassium ; carbonates, phosphates, 

and sulphates of potash and soda 8*37 

Carbonates of lime and magnesia ; phosphates of lime, mag- 
nesia, and iron; peroxide of iron 4-50 



1000-00 



In a healthy and normal condition of the human system we find 
always the existence of a relationship between the requirements 
and material of supply which should, and which does, afford proper 
tissue ; where, then, such conditions exist, the teeth, caeteris paribus, 
are perfectly formed, and, as constitutional relations are concerned, 
are healthily preserved. 

In the study of the pathological conditions of these organs, we 
are to discover, if possible, wherein the harmony of demand and 
supply is or has been interfered with ; and that we may look at the 
subject from the most comprehensive standpoint, we must stud} r 
not only hereditary complications which may exist, but are to 
understand as well the direct relations of the developing organs. 
This brings us to the subject of nutrition proper. In this connection, 
I know of no one who has given a more exhaustive attention to the 
subject than the late James Paul, M.D ; and I recognize that I 
could not afford the subject better expression than by embodying 
the substance of a paper read by that gentleman before the Medical 
Society of Mercer, N. J. The views cannot receive a too careful study. 

''The subject," says Dr. Paul, "is, not only in a physiological 
point of view, one of interest, but in its application to the preserva- 
tion of health — the tendency to improve the general condition and 
physical constitution of the human family inhabiting this great con- 
tinent — a continent abounding, as it does, in all the productions 
which a bountiful Creator in his beneficence bestows on man — 
cannot be otherwise than of great and paramount importance. 

" At a period now somewhat remote, the celebrated naturalist 
Buffon, alluding to the animals of this continent, advanced the fol- 
lowing opinions: 



230 ORAL DISEASES AND SURGERY. 

" 1. That the animals common both to the Old and the New World 
are smaller in the latter. 

" 2. That those belonging to the New are on a smaller scale. 

"3 That those which have been domesticated in both have de- 
generated in America. 

"4 That, on the whole, it exhibits fewer species. 

"These opinions Mr. Jefferson, in his 'Notes on Virginia,' under- 
took, and, it is generally considered, successfully, to controvert ; yet, 
however repugnant to the general idea the opinion as to the tend- 
ency of those animals which have been domesticated in America 
from other countries to degenerate, it is an undeniable and much-to- 
be-regretted fact that the human family, and more particularly the 
female portion of that family, have declined in the vigor and strength 
of their physical constitution. 

"I wish not to be misunderstood : I say it is a melancholy fact, 
too well known to the observant physiologist, that increase of 
strength and development of frame have not been attained by the 
intermarrying of members of the human family of different nations 
on this continent; but the reverse is too observable; the physical 
frame of the female sex has degenerated, — calling loudly for the aid 
of science to arrest an evil of so much magnitude. 

" Let us for a moment contemplate the female form, as seen on 
this broad continent. In no country in the world are children more 
fair and beautiful ; and as the young girl grows up to womanhood, 
we see in her a full realization of that being forming in the hands of 
Divinity, portrayed by the poet, as seen by Adam in his dream : 

" ■ Under his forming hands a creature grew, 
Manlike, but different sex; so lovely fair 
That what seemed fair in all the world, seemed now 
Mean, or in her summed up, in her contained, 
And in her looks.' 

"We see this young and lovely being — the forehead well de- 
veloped, the countenance, rather elongated, relieved of the harsher 
outline of some of the European nations, with fragile form and 
small yet well-developed bust — flitting for a few short years among 
us, and then — yes, then — there comes a change. Ere five-and- 
twenty summers pass, this flower begins to fade — the rounded form 
shrinks — the bloom of health decays ; and if she escapes the fell 
destroying angel's deathlike grasp, a wreck of former self remains. 

''Why should this be so? The robust of other countries come 



THE TEETH AND THEIR DISEASES. 281 

to this continent. They live in comfort; their food is excellent in 
quality; their progeny is like themselves; but even now, in the 
very first generation, does the degenerating process make itself 
manifest, — the teeth begin to decay; and girls, while yet children, 
have to visit the dentist to have them cleansed, scraped, and 
plugged. 

"Now, this brings us at once to the head and front of our subject ; 
and if we can point out the first cause of this decay of what should 
be as strong as adamant, it may be the means of helping us in our 
investigation. That there is something radically wrong in our sys- 
tem of rearing the young, to which this misfortune is in a great 
measure owing, I am free to confess is mj firm opinion. I would 
indeed it were in my power, in pointing out the evil, to be as suc- 
cessful in detailing the cause, that we may apply the remedy. Still, 
although perhaps unable to accomplish all I wish, my observations 
may not be without their weight, and induce others, more observant, 
more scientific, and more competent to the task, to follow up an 
investigation so fraught with advantage to our fellow-beings. 

"It is certainly to be deplored that the females of this continent, 
descendants of European parents, should be so much afflicted with 
caries of the teeth, the decay of parts formed of substances which 
enter into the composition of some of our hardest minerals, — marble, 
bone-earth, and fluor-spar; and this decay unfortunately occurs in 
early life, — in girls yet at school ; and many a young woman, ere 
she has attained a marriageable age, has had to replace the natural 
with the unnatural though more enduring enamel of the artist's 
formation. This ought not to be : God made all mankind alike ; in 
no portion of the earth are nations found who lose their hands, or 
feet, or tongue, or eyes ; and there can be no cause why the inhabit- 
ants of this land should lose their teeth. It is not so in the olden 
countries from whence the progenitors of the present race have 
come: nor is it so in the West India islands, which may almost be 
considered as part of this great continent. So excellent is the struc- 
ture of the teeth of savage nations, that some tribes in Africa, I 
think the Mocoes and Mandingoes, file all the front teeth, so that 
they shall be separated and form sharp points, the better to tear 
the uncooked animal food. 

"One cause of this affliction is, in the minds of many, attributed 
to the great and sudden changes of temperature experienced on this 
continent, — the thermometer rising and falling twenty, thirty, and 
even forty degrees in twelve hours. But if attributable to these 



232 ORAL DISEASES AND SURGERY. 

sudden changes, we know that sudden expansion by means of heat, or 
sudden contraction by means of cold, causes the particles of which 
bodies are composed to tear themselves asunder ; consequently, to 
crack, break, and fall in pieces. But this is not the case with the 
teeth of our females; a caries or decay commences most generally 
in the side of the tooth, extending to the enamel, which is some- 
times involved in the destruction ; at other times it is left a crust 
or shell to snap and break off in small pieces, when unable to resist 
the pressure of whatever may be placed against it; besides, the 
teeth are for the most part sheltered from these sudden changes, 
and kept at a temperature nearly amounting to blood-heat at all 
seasons. I do not think we can place the general destruction of the 
teeth, and consequent affliction of the females of America, to this 
cause. I fear we must rather look for it to constitutional weakness, 
and this constitutional. weakness to a deficiency of the inorganic or 
earthy constituents being taken into the system, more particularly 
at an early period of life.* 

"If I am correct in this opinion, — and reason, philosophy, and a 
thorough examination of physiological facts in both the animal and 
vegetable economy, tend far to bear out these views, — then if we 
would try and correct this lamentable state of things, let us com- 
mence at the very beginning, and make ourselves acquainted by 
examining the structure and composition of the teeth, and then we 
shall be more able to understand what is required to aid nature in 
their formation and consequent preservation. 

" First, then, let us make ourselves acquainted with the structure 
and composition of the teeth. The teeth are nearly allied to bone 
in structure ; both having earthy deposits, intermixed with fibres 
and cells of gelatin, which, by consolidation, gives form and strength, 
in the case of bone, to bear the weight of the various parts and 
afford protection to the different organs of the body; and in the case 
of teeth, to cut and grind the food required for the formation, sup- 
port, and reparation of its various parts. 

"Now, teeth are composed of three different substances, and 
these three are disposed according to the purposes required of them ; 
they are cementum or crusta petrosa, dentine (known as ivory in the 
tusk of the elephant), and enamel. The cementum or crusta petrosa 



* Experiments have demonstrated that teeth may be changed instantly 
from iced to boiling water without cracking the enamel. Injury to the teeth 
from thermal changes would arise rather from irritation inflicted on the pulp. 



THE TEETH AND THEIB DISEASES. 233 

corresponds in all essential particulars with bone, possessing its char- 
acteristic lacunae or small cavities, and being traversed by vascular 
medullary canals, whenever it occurs of sufficient thickness ; it is 
the first covering of the young tooth, and may be said to invest the 
fang of the tooth which enters the alveolar process of the jaw. The 
dentine, or ivory, consists of a firmer substance, in which inorganic 
or mineral matter predominates, though to a less degree than in 
enamel. It is traversed by a vast number of very fine, cylindrical, 
branching, wavy tubuli, which commence at the pulp cavity and 
radiate toward the surface. The diameters of these tubuli, at their 
largest part, average about l-10,000th of an inch ; their smallest are 
immeasurably fine ; so much so, that they cannot possibly receive 
blood, but it is surmised that, like the canaliculi of bone, they imbibe 
fluid from the vascular lining of the pulp cavity, which aids in the 
nutrition of the tooth. The enamel is composed of solid prisms of 
fibres, about the l-5600th of an inch in diameter, arranged side by 
side, and closely adherent to each other; their length corresponds 
with the thickness of the layer which they form ; and the two sur- 
faces of this layer present the ends of the prism, which are usually 
more or less hexagonal. In the perfect state, the enamel contains 
but an extremely minute quantity of animal matter. In the centre 
Of the tooth is the soft pulp cavity, which affords a bed for the 
blood-vessels and nerves which supply it with life and sensibility. 

"I shall not enter more minutely into the structure of the teeth, 
but may briefly state that, like all other structures of the animal 
body, the component parts are derived and deposited from the 
blood, by that mysterious and incomprehensible power that selects 
and deposits the necessary constituents in the formation of the 
several portions, according to the use required. 

"Now, in the composition of the teeth, we have first the division 
into organic and inorganic or earthy matter; and we find that the 
several substances which enter into the structure of the teeth differ 
chiefly as to the earthy matter contained in each. 

"Chemical analysis of the incisors, or front teeth of man, shows 
that they contain in one hundred parts of each, as follows : 

Cementum. Dentine. Enamel. 

Organic matter 29 27 28-70 8 59 

Earthy matter 7073 7130 96-41 



100- 100- 100- 

" These proportions will occasionally differ ; in some individuals 



234 ORAL DISEASES AND SURGERY. 

the organic constituents having less than here stated, amounting in 
the dentine only to 21. The analysis of bone, however, gives a 
much larger proportion, — viz. : 

Organic matter 82-56 

Earthy matter 67-44 

100- 

"Let us now take a more complete analysis, showing what earthy 
constituents enter into their composition. Analysis of the molar or 
grinding teeth of man, and of the bones of the arm and leg of a 
man of forty, shows the following proportions: 



Dentine. Enamel. Bone. 
Inorganic matter: 

Phosphate of lime, with traces of filiate of lime 6672 8982 54-61 

Carbonate of lime 3 36 4-37 9-41 

Phosphate of magnesia 1-08 1-34 107 

Salts, etc -83 -88 2-35 

Organic matter 28 01 3-59 32-56 

100- 100- 100. 

" Thus we see the very great proportion of certain earths that 
enter into the structure of the teeth and the bones of man, the chief 
substance being the phosphate of lime, familiarly known as bone- 
earth. We find, too, that whereas in ordinary bone the phosphate 
of lime constitutes only 54 parts in 100, in the enamel of the teeth 
it is nearly 90 parts in 100; while the carbonate of lime in bone 
amounts to 9"41, in the enamel of teeth it is only 4*3*7, — the enamel 
being literally almost a mineral in substance, having only 3.59 parts 
of animal matter in 100. 

" Thus the teeth, to be strong and durable, require a large 
quantity of earthy ingredients, particularly lime, to enter into their 
composition. Let us inquire whence it is derived; and for this 
we must examine the blood. 

" To allow of such deposits from the blood, it is first necessary 
that they should be held in solution in that fluid. The blood circu- 
lates to every portion of the body by the action of the heart, which 
forces a certain quantity — say two ounces at every contraction — 
into the aorta or great canal leading from the left ventricle. The 
aorta divides and subdivides into innumerable branches, which are 
made to ramify to every part of the body, until the extreme branches 
end in capillary tubes or vessels, the calibre of which is so small as 



THE TEETH AND THEIR DISEASES. 235 

not to allow the red globules or corpuscles of the blood to enter 
them, but which allows the serous portion to traverse every part of 
the organized structure, holding in solution all those constituents 
necessary and requisite for the formation and reparation of its several 
parts. 

" In the serous portion of the blood, then, we find contained 
the constituents required for the composition of bone and teeth, — 
analysis of 1000 parts of healthy human blood giving, according to 
M. Lecanu, the following proportions : 

Water -. 780-15 785-58 

Fibrin 210 3-57 

Albumen 65-09 69 41 

Coloring matter 133-00 119-63 

Crystallizable fat 2-43 4-30 

Fluid fat 1-31 2-27 

Extractive matter, uncertain 1-79 1-92 

Albumen in combination with soda 1-26 2 01 

Chlorides of sodium and potassium ; carbonates, 

phosphates, and sulphates of potash and soda... 8-37 7-30 
Carbonates of lime and magnesia ; phosphates of 

lime, magnesia, and iron; peroxide of iron.... 2-10 142 

Loss 2-40 2-50 

1000- 1000- 

"We see by this table, if we subtract or take away the proportion 
of water, amounting to 180 parts, and the coloring matter, amounting 
to 133, we shall leave scarcely 90 parts of organic and earthy ma- 
terial, the salts and earths forming upwards of a 10th, — the salts 
being in proportion to the earths as 4 to 1. 

" Having then shown the constituent portions of the bones and 
teeth to be in the blood, the next consideration is, whence are they 
derived ? 

"Before entering on this subject further, let us for a moment take 
a broader and more comprehensive view of what must be most 
interesting to mothers, and of great consequence to the well-being 
of the infant generation, in a short time, in a very few years, to 
become in their turn the mothers and fathers of another generation. 

"The question then presents itself, what is the nourishment or 
food best adapted and necessary to the wants of an infant, that the 
foundation may be laid for a strong frame and vigorous constitution ? 
For here, we must recollect, is the starting-point in by far the ma- 
jority of instances. We know that in some cases disease is hered- 



236 ORAL DISEASES AND SURGERY. 

itary, — that the offspring unfortunately inherits from the parents 
constitutional defects ; but we also know that more misery, suffer- 
ing, and constitutional derangement are entailed on children by 
want of care and improper food in the first years of life, by 
which their hopes of health are blasted, and they are doomed to 
struggle through a weary life, to be hurried at last into a premature 
grave. 

"Now, that the frame — that is, the bones, muscles, and other 
portions — of the infant may be fully developed, it is necessary that 
it should be supplied with nourishment containing all the constitu- 
ents required for this important undertaking. And this nourish- 
ment, by the all-wise ordering of Providence, is contained in the 
milk secreted from the mother's bosom. 

" The infant is entirely dependent on the nourishment derived 
from its mother, and nature has wisely ordained that the secretion 
from the mother is its very best food ; for we find in the composi- 
tion of milk — that is, healthy milk, derived from healthy blood — 
all those ingredients we have hitherto traced as requisite in the 
formation of the bones and teeth, and not only these, but every con- 
stituent required for the life and growth of the individual ; milk 
containing the albuminous, saccharine, oleaginous, saline, and earthy 
compounds requisite and necessary for the health, strength, and de- 
velopment of the infant child. 

"An analysis of cow's milk gives the following proportions of the 
various constituents'; that of human milk is not so elaborate, but 
contains the average of observations taken at fourteen different times 
from the same individual, by Simon. 

Cow's Milk, by M. Haldlen. 

Water 87300 

Butter 3000 

Casein 48-20 

Milk sugar 43-90 

Phosphate of lime 2-31 

Phosphate of magnesia 42 

Phosphate of iron -07 

Chloride of potassium 1-44 

Chloride of sodium -24 

Soda in connection with casein -42 

1000. 



THE TEETH AND THEIR DISEASES. 237 

Woman's Milk, by Simon. 

Water 883-6 

Butter 25-3 

Casein 34 3 

Milk sugar and extractive matter 48-2 

Fixed salts 2-3 

1000. 

Maximum of Minimum of 

14 observations. 14 observations. 

Butter 540 80 

Casein 45-2 10 6 

Sugar and extractive matter 62-4 39-2 

Salts 2-7 1-6 

"Now, although these amounts will no doubt vary, under every 
variety of circumstances, according to the health, exercise, passions, 
and food of the mother, yet they show that healthy milk contains 
all the requisites for the nourishment of the infant ; but then it must 
be healthy milk, secreted from healthy blood, and that blood must 
derive these ingredients from the food consumed. 

" Cow's milk differs from that of woman in the proportions of 
some of the constituents: it abounds more in butter, but particularly 
in casein, or cheese; and, on the other hand, human milk abounds 
more in the saccharine principle, or sugar of milk. Now, this points 
out a circumstance from which great benefit may be derived. It is 
of very frequent occurrence that infants are deprived of the natural 
nourishment of the mother, and diverse opinions are given relative 
to the food of infants by persons who really know very little about 
the matter ; one recommends a milk diet, another that the infant 
must be fed on starch and sugar. 

" Now, to enable the infant to receive a nourishment in every re- 
spect similar to the mother, the knowledge of the various propor- 
tions which we obtain by chemical analysis enables us to rectify 
and produce milk very analogous to human milk from that of the 
cow, by diluting it with water in the proportion of about half as 
much again ; that is, to a pint of milk should be added half a pint of 
water that has been boiled, which will reduce the cheese principle to 
the proper proportion ; add a small portion of cream to restore the 
proportion of butter, and then add sugar until the whole is dis- 
tinctly sweetened, and we have a compound in every respect similar 
to the milk from the human breast. 



238 ORAL DISEASES AND SURGERY. 

"To understand the subject of nutrition, let us remember that 
food should, or must, embody two great principles : one to nourish, 
the other to give heat to the body. And food, when consumed, is 
applied to one or the other of these purposes. Now, in the process 
of digestion, the constituents of the food are separated, and arranged 
in three classes: 

" 1st. All that portion derived from animal food, eggs, the curd 
of milk, the gluten or adhesive portion of wheat and other grain, 
and whatever in animal or vegetable food can be rendered into albu- 
men — of which the best example that can be offered in illustration is 
the white of egg, which is in reality nearly pure albumen — and the 
principle is therefore called albuminous. 

" 2d. All that portion of the food derived from vegetables, starch, 
sugar, etc. that can be converted into sugar in the process of diges- 
tion. This principle is therefore called saccharine. 

" 3d. All the fat, butter, oil, etc. which, when deprived of the 
other substances, is left in the state of oil, and therefore called ole- 
aginous. 

"Now, of these three the albuminous is the nutrient, and the 
saccharine and oleaginous are the color if acient, or heat-giving ; and 
chemical analysis shows that they vary in composition. 

ALBUMINOUS. OLEAGINOUS. 

Eggs. Wheat. Muttou fat. 

Carbon 55-000 5501 78996 

Hydrogen 7-073 7-23 11-700 

Nitrogen 15920 15 92 

Oxygen ^ 9304 

Sulphur I 22-007 21-84 

Phosphorus ) 



SACCHARINE. 



Starch, Sugar Sugar Cane 

arrow-root, from starch, of milk, sugar. 

Carbon 44 40 37 29 40 00 42 301 

Hydrogen 6-18 6 84 6-61 6-384 

Oxygen 49-42 55 87 5293 51-315 

" It will be observed that the albuminous or nutrient differs from 
the saccharine and oleaginous, in containing nitrogen, and sulphur 
and phosphorus, with carbon, hydrogen, and oxygen, while the latter 
contains only carbon, hydrogen, and oxygen, — nitrogen being re- 
quired in those compounds which give strength and formation to 
the frame. 



THE TEETH AND THEIR DISEASES. 239 

" Now, the albuminous or nutritive, being that portion which 
affords nourishment to the body, contains those constituents re- 
quired in the first place for the formation and giving strength to the 
different portions of the body, and, when fully developed, of repair- 
ing the general waste continually going on in the system, whether 
from the usual wear and tear, fractured bones, or the ravages of 
disease. And the saccharine and oleaginous — the calorifacient or 
heat-making — to keep up a continual supply of fuel, as it were, that 
the body may be kept of a regular and proper temperature ; for all 
are no doubt aware that there is a continual supply of carbon, or, 
in more simple language, of charcoal, required to keep up the natural 
temperature of the body; and what is not required for immediate 
use is stored away in the form of fat, to be called into action as 
occasion requires. 

" We have seen in the analysis of milk that that fluid contains 
butter, cheese, and sugar ; consequently we can understand how an 
infant can thrive so well upon it, — the cheese or casein* of the 
milk containing the nitrogenized or nutrient principle, which, to- 
gether with the earths and salts contained in the milk, goes to form 
the bones, muscles, and the different tissues of the body, — the sugar, 
which, we have seen by the analysis, contains a large quantity of 
carbon in its composition, going to keep up the temperature of the 
infant, while the butter, in the nature of fat, is stored away in a 
healthy infant, filling up every vacant interstice, causing a round- 
ness and plumpness, the pride and joy of the happy parent. 

"Now, let us mark the difference of the babe that has been denied 
a milk diet, and is doomed by ignorance to be fed on starch and 
sugar. We will recollect that these two substances are composed 
of carbon, hydrogen, and oxygen only. By a process of digestion 
which I need not here enter into, such food is converted into sugar, 
the carbon of which becomes the fuel by which the temperature of 
the body is kept up ; there being no principle in the food to give 
albumen, there is nothing taken into the stomach upon which the 



* Carbon.... 
Hydrogen. 

Nitrogen.. 



Oxj^gen 
Sulph 



ur J 



Analysis of 


Albuminous substances found 


casein from 


in whej 


after coagulation 


fresh milk. 


wi 


th an acid. 


54-825 




54-96 


7-153 




7-15 


15-628 




15-89 
21-73 


22.394 




0-36 



240 ORAL DISEASES AND SURGERY. 

gastric fluid can expend its solvent powers ; the infant is, therefore, 
much troubled with acid eructations, and the stomach becomes weak 
and irritable. The want of the nutritive constituent of the food, 
and the earths and salts, etc. necessary and essential for the forma- 
tion of the bones and teeth, show a lamentable deficiency in the 
child's development ; and there being no fatty matter to be laid up, 
the body is emaciated, the countenance is ghastly, the flesh and in- 
teguments hang soft and flabby over the bones; no absolute disease 
can be detected; the child is ravenous and hungry, and the unfortu- 
nate babe descends to the tomb a spectre and an object of the most 
pitiful description. This is no fancy sketch, but one too often met 
with in the ordinary walks of professional life. And why is it so ? 
Simply because the composition of the human frame, the component 
parts of our food requisite to produce that frame, and the process of 
digestion and nutrition, are so little understood. 

" We now advance from infancy to childhood ; and this is a period 
when the greatest attention is required in supplying nutriment to 
aid nature in the great work of developing the body. The child is 
now deprived of the maternal secretion, and dependent on food pre- 
pared for its use by the hand of man, — perhaps living in a city, and 
deprived of pure and wholesome milk from the cow. And we know 
there is a vast disproportion in the quality of milk when the cow is 
country-fed on the natural productions of the farm, and when city- 
fed on slops and grain, the refuse of the brewery. 

" It is at this age that the great proportion of bony substance is 
deposited ; those of the extremities are lengthened, become more 
compact and stronger, and the substance of the teeth is deposited 
in the cells of gelatinous tissue. How necessary is it, then, that 
this subject should receive the utmost attention of parents! It has 
hitherto been too much the custom to leave all this, as belonging 
entirely to nature, as a thing we had nothing to do with. We have 
been too much in the habit of considering that nature furnished her 
own materials, and man had nothing to do with her operation. The 
potter cannot fashion the bowl without the clay, neither can bone 
be formed without earth : nature must be supplied with the material, 
which, although offered in the most incongruous forms, she has the 
pow r er of decomposing, selecting from, and supplying for the various 
purposes required : one portion, as we have already stated, to act as 
fuel in keeping up the temperature ; another portion she selects to 
add to the flesh, the muscle, skin, and different tissues; and the 
earths which are held in solution she carries away by vessels 



THE TEETH AND THEIR DISEASES. 241 

adapted for that purpose, and deposits them atom by atom, until 
they are so compressed, so strongly compacted together, as to 
become what we call solid bone, — and all this so wonderfully 
wrought that, as we have seen, small tubes are left in the hard, 
stony formations both of the bones and of the teeth, that nourish- 
ment may be supplied them, holding in solution the material of 
which they are composed, that the natural waste and decay may be 
replaced and injuries repaired. 

" It is to this nutrition, and to the earthy matter of which the 
bones and teeth are composed, a deficiency of which is attended 
with results so deplorable, that I particularly wish to call attention. 

" To what can we attribute the calamity which too often befalls 
the young? I allude to distorted spines, where the bones com- 
posing the spine, instead of forming a column, allowing the body 
to be erect and dignified, are zigzag in their course, causing one 
shoulder to bulge out, and the opposite side to bend or double upon 
itself. This deformity has been long understood to arise from a 
deficiency of lime in the composition of the bones of the vertebrae, 
allowing them to fall, press upon, and injure each other, destroying 
the beauty of the fabric and the health and comfort of the indi- 
vidual. 

" Now let us take a glance at the inhabitants of two countries, 
natives of which are no strangers on this continent. I take them 
as examples, because the food of the common people of those coun- 
tries is well known to be of the most common kind. I allude to 
natives of Scotland and Ireland, — the principal food of one being 
oatmeal, and of the other potatoes. We have heard a great deal of 
the famishing poor of those countries, and particularly of the latter, 
of the misery and wretchedness seen in every hovel ; and there 
cannot be a doubt that famine walked through the land when the 
blight and rot despoiled them of their potato crop, on which for so 
long a period they depended as the great article of food. Now, 
allowing all this, — allowing, in the best seasons, the chief article of 
subsistence has been potatoes for breakfast, dinner, and supper ; 
— glad indeed many of them to get a little animal food once a week 
to dinner, or even far more seldom, — I now ask, what number, in 
the thousands of emigrants from that country who yearly arrive at 
our ports, are there that show a constitution weak, fragile, and 
wanting in physical strength ? Many, no doubt, arrive worn down 
by disease and suffering, and in the last stage of debility ; but let 
them recover from that state, and the robust frame and healthy con- 

16 



242 ORAL DISEASES AND SURGERY. 

stitution will be again developed ; the bones are strong, the teeth 
undecayed, and the muscular energy only wanting opportunity to 
display itself; — in fact, when we wish to denote strength in woman, 
we use the familiar phrase, ' strong as an Irishwoman,' and all 
this from being reared on potatoes* But then, if we examine the 
analysis of the potatoes, we shall find contained in 100 parts of dry 
potatoes, — 

Carbon 41 1 

Hydrogen 5 8 

Nitrogen 



48-1 
Oxygen J 

Ashes 50 

" Here we see that potatoes not only contain the nutrient but the 
earthy constituents. 

" But we have a stronger and more healthy race yet, from Scot- 
land and the north of Ireland, who are generally descendants of the 
Scotch, and continue, in a great measure, the same means in rearing 
the young. Now, a principal — I will not say the principal — food of 
the youth of Scotland, high and low, rich and poor, except in the 
larger cities, among those who class themselves as more refined and 
more civilized, but who number few in proportion, consists, for 
breakfast, at least, of oatmeal, — that is, porridge and milk; and 
milk, potatoes, and wheaten, oaten, or pease bread, or bannocks, at 
other times of the day. Animal food among the poor is a rarity, a 
meat dinner on Sunday only being common. Even among the youth 
of the better class, butcher's meat, or animal food, is by no means a 
principal article of subsistence. And I would particularly remark 
that Scotch oatmeal (the oatmeal generally used throughout Scot- 



* According to a memorial presented to the French minister, on the pro- 
portions of nutriment of the means of living, by Dr. Glaser, we find potatoes 
taking no mean rank. 

NUTRITIVE ELEMENTS. 



100 lbs. wheat bread contains 30 lbs. 
" flesh " 21 lbs. 



:i 



fresh beans " 80 lbs. 

peas " 83 lbs. [-casein and starch. 

lentils « 94 lbs. J 

potatoes " 25 lbs., albumen, starch and sugar. 

carrots " 14 lbs. 1 

beets « 8 lbs. / albumen with su S ar - 



THE TEETH AND THEIR DISEASES. 243 

land) is coarse, and contains much of the bran which invests the 
oat, — containing, as it does, a large proportion of the earthy con- 
stituents required for the production of bone. Analysis of 100 parts 
of dried oats gives — 

Carbon 5-07 

Hydrogen 6*4 

Oxygen 36-7 

Nitrogen 2-2 

Ashes 40 

"I may here casually remark, that the advantage to be derived 
from this wholesome food has not escaped the observation of her 
Majesty, Queen Victoria, who appears in the multiplicity of her 
public duties not to lose sight of the equally sacred duties of a 
mother; and we hear of her son, the heir to the crown of Great 
Britain, being as fond of his oatmeal porridge as the meanest 
peasant child in Scotland. 

" I rather doubt if parents generally have given to this subject 
the attention to which it is entitled. I trust, however, that those 
who have followed me thus far, may be impressed with its impor- 
tance. We cannot shut our eyes to the complaint which so gen- 
erally prevails of decayed teeth ; and a moment's reflection will call 
to mind the number of the young and beautiful who are prematurely 
hurried to the tomb, ere yet the bud has expanded into the full- 
developed flower. Nay, comparing the two countries, the statistics 
of life and death communicate to us also the important fact, that 
while the greatest mortality shows itself in England in infancy and 
childhood, on this side the Atlantic it is found at a more mature age. 

"Neither has the tendency of the physical organization of woman 
on this continent to degenerate escaped the observation of one of 
our greatest medical philosophers in this country,* who regards this 
retrogression as a national calamity, and impresses upon his 
students the importance of the subject, and the propriety of their 
attention in attempting to arrest it; and he particularly specifies 
the great object to be gained in the use of bran-bread made from 
unbolted flour. On this head I shall have more to say hereafter. 

"With these observations, let us now direct our attention to what 
can be offered in remedy of this evil. 

"We have already stated that in no country in the world are 

* Prof. Samuel Jackson, of the University of Pennsylvania. 



244 ORAL DISEASES AND SURGERY. 

children more beautiful or more lovely — healthy in complexion, 
quick, smart, and intelligent — active, sprightly, and playful in their 
disposition. Now, in the period from infancy until the child 
becomes mature, — let us, at all events, say until thirteen or fourteen 
years, and even to a more advanced age, — there is a continued 
growth, — a continual deposition of organic and inorganic or earthy 
particles, which are required for the formation of bone, teeth, flesh, 
and every part of the human body. I have shown that the essential 
ingredients for these several formations are all found in the milk of 
the mother; consequently, as long as the infant is deriving nourish- 
ment from the mother, she ought to partake of good, wholesome, 
nourishing food, that the blood, deriving these principles from the 
food, may be able to supply them in turn to the milk from which it 
is secreted. So long, then, as the child is thus nourished, so long 
is it safe, and the rudiment or foundation of a robust frame is laid. 
And if we are to expect, in future life, the stalwart frame of man, or 
the enduring, firmly-knit, compact, and healthy physical constitution 
in woman, the organic and inorganic or earthy compounds of which 
that frame is composed must not be denied. Nature must be sup- 
plied, or nature will fail. 

"It is not for me to dictate to any parent what shall be the food 
of his child: it is enough that I point out for their information what 
may be required to give what in common language is called 'bone 
and sinew' to their offspring. It is necessary, then, that the food 
of children shall contain: 

" 1st. Aliment having the calorifacient or heat-sustaining prin- 
ciple. And this is contained in quite sufficient quantity in the usual 
food, — in milk, wheaten bread, potatoes, arrow-root, Indian corn (as 
mush, hominy, or corn-bread), in most vegetable matter, and in 
sugar. 

" 2d. Aliment containing the nutrient principle. And this is con- 
tained in animal food, — the lean of beast, bird, and fish, — in milk, 
eggs, wheat, rye, potatoes, beans, etc. 

"And 3d. Aliment containing the inorganic or earthy constitu- 
ents, — on which depends strength of frame, and from which are 
formed the bones and teeth of the individual. And these are con- 
tained in milk, eggs, animal food, and particularly in wheat, rye, 
oats, potatoes, etc.* 

* On this subject, I extract the following from Carpenter's Physiology, 
p. 488: "These substances are contained, more or less abundantly, in most 



THE TEETH AND THEIR DISEASES. 245 

" Of the inorganic constituents contained in wheat (and the same 
may be said of the other cereal grains) I have already alluded to 
the benefit to be derived from using bread made of unbolted flour. 
On this siibject allow me to refer to the difference of flour having 
much of the bran remaining, and superfine flour, or that in general 
use throughout this country, and on which Prof. Johnston has made 
the following curious but practical observations. Examining wheat 
and flour, as to the amount of the nutrient or muscular matter, the 
fat-forming principle, and the bone and saline material, contained in 
grain in different states, he found — 

Muscular matter. Fat principle. Bone and salt. 

In 1000 lbs. of whole grain 156 lbs. 25 lbs. 170 lbs. 

" " fine flour 130" 20" 60" 

" " bran 60 " 700 " 

"Taking the three substances together, according to Prof. John- 
ston, of a thousand pounds, the three substances contain of the in- 
gredients mentioned, — 



articles generally used as food ; and where they are deficient, the animal suffers 
in consequence, if they are not supplied in any other way. Thus, common 
salt exists, in no inconsiderable quantity, in the flesh and fluids of animals, 
in milk and in eggs; it is not so abundant, however, in plants; and the 
deficiency is usually supplied to herbivorous animals by some other means. 
Phosphorus exists also in the yolk and white of the egg, and in milk; and it 
abounds not only in many animal substances used as food, but also (in the 
state of phosphate of lime or bone-earth) in the seeds of many plants, espe- 
cially the grasses. In smaller quantities, it is found in the ashes of almost 
every plant. Sulphur is derived alike from vegetable and animal substances. 
It exists in flesh, eggs, and milk; also in the azotized compounds of plants; 
and (in the form of sulphate of lime) in most of the river- and spring-water 
that we drink. Iron is found in the yolk of egg and in milk, as well as in 
animal flesh ; it also exists in small quantities in most vegetable substances 
used as food by man, — such as potatoes, cabbage, peas, cucumbers, mustard, 
etc. Lime is one of the most universally diffused of all mineral bodies; for 
there are few animal or vegetable substances in which it does not exist. It 
is most commonly taken in, among the higher animals, combined with phos- 
phoric acid : in this state it exists largely in the seeds of most grasses, and 
especially in wheat-flour. If it were not for their deficiency of lime, some of 
the leguminous seeds (peas) would be more nutritious than wheaten flour ; 
the proportion of azotized matter they contain being greater. A consider- 
able quantity of lime exists, in the state of carbonate and sulphate, in all 
hard water." 



246 ORAL DISEASES AND SURGERY. 

Whole grain. Fine flour. 

Of muscular matter 156 lbs. 130 lbs. 

Of bone material 170 " 60 " 

Offat 28 " 20 " 

354 lbs. 210 lbs. 

"Accordingly, the whole grain is one-half more nutritious than 
fine flour.* It also shows the very great proportion of bone mate- 
rial — that is, earthy constituents — contained in the bran ; no less 
than TOO out of a thousand parts, or a little more than two-thirds of 
the whole. Now, by reference to the same work, we find, in a com- 
munication from a Mr. Bentz, the difference in weight of a barrel of 
flour without the bran, and when only the outer coating of the wheat 
is taken off. He says, 'The weight of the bran or outer coating 
would, therefore, in the common superfine flour, constitute the offal, 
weighing only 5^ lbs. to the barrel of flour, while the ordinary 
weight of offal is from 65 to TO lbs. to each barrel of flour ; showing 
a gain of from 59 j to 65 lbs. of wheat in every barrel of flour.' Now, 
if we estimate the earthy constituents to be two-thirds of the offal 
or bran, we must consider that there is an actual loss of these im- 
portant constituents, which might be reserved, in every barrel of 
flour, of 40 lbs. 

11 Again, if we estimate (according to the average of the consump- 
tion of flour to the amount of population, as one barrel to each indi- 
vidual) that every child shall consume annually only half a barrel of 
flour, then we find that by the use of the superfine flour, as com- 
monly used in families, the child is deprived yearly of twenty pounds 
of those earthy substances which are required to form the bones and 
the teeth. When we speak of a child consuming half a barrel of 
flour annually, it appears a large quantity; but when we reduce the 
same to a daily allowance, we find that it is little more than 4 oz. or 
4^ oz.; and every parent must know that this would be a very small 
amount to limit children to. Yet we see how large a quantity of the 
bony material would be added if unbolted flour was used instead of 
the present superfine flour. I may here add that the oatmeal used 
in Scotland, already referred to, contains the bran or inorganic con- 
stituents, while the oatmeal used in England is deprived of it. Now, 
this is a great loss of the most valuable constituents in only one of 
the principal articles of the food of children; and if we allude to 
:another article, which is largely used on this continent, — I mean 



* Patent Office Eeport, 1847, p. 116. 






THE TEETH AND THEIR DISEASES. 247 

Indian corn (and I may also add the fat of meat, both of which, 
children, if allowed, will partake of very freely), — we shall find that 
both of these abound more in the calorifacient or heat-sustaining 
principle, and for the deposition of fat, than the nutrient, and that 
they are quite deficient in the earthy material of lime, — that material 
on which so much depends the proper structure of the teeth. An- 
alysis of Indian corn shows the following composition, — as taken 
from Mr. Salisbury's prize essay read at the New York Agricultural 
Society for 1849 : 

Whole kernel. 

Starch 50 64 

Sugar and extractive 7 46 

Sugar 1 50 

Fibre 6-28 

Matter separated from fibre 0-05 

Albumen 8 64 

Casein , 1-70 

Gluten 4-56 

Oil 400 

Dextrine or gum 4 84 

Water 10-22 

99-89 
Ash of the kernel, constituting about two per cent. 

Carbolic acid a trace. 

Silicic acid 1-450 

Sulphuric acid 0206 

Phosphoric acid 50 955 

Phosphate of iron 4-355 

Lime 150 

Magnesia 16-530 

Potash 8-286 

Soda 10-908 

Chloride of soda 0-249 

Organic acid 3-400 

97-000 

" This is a most elaborate analysis, — far more minute than any 
analysis we have had of any of the articles of food, — in fact, more 
minute than satisfactory; for the analysis of the whole kernel does 
not exhibit any amount of inorganic constituent; and when the 
whole is converted into ashes, we find that the lime only amounts 
to the one-sixth of one part in a hundred. Now, on inquiry, I find, 
on the authority of a very intelligent miller of this city, that in 



248 ORAL DISEASES AND SURGERY. 

grinding corn the bran or thin skin of the grain is detained in 
forming it into corn-meal ; consequently, it is deprived of even 
that portion more particularly containing the earthy constituents. 
This gentleman, in conversation, mentioned an important fact rela- 
tive to this deficiency of lime in corn. To the best of my recol- 
lection, he observed, ' This stands to reason ; for, ten years ago, 
all the lower part of Jersey grew excellent corn, but would not 
grow wheat ; but since the introduction of lime as a manure they 
have raised considerable wheat crops.' Now, the fact is, it is not 
the habit or food of this plant, even had lime been in the earth; and 
magnesia and the saline manures are recommended to the agricul- 
turist as best suited for its proper development. 

"It is generally looked upon as invidious, and one is more likely 
to incur odium than to receive credit for saying one word against a 
food which stands so high in public estimation and is so universally 
used over this continent. Yet it must not for one moment be sup- 
posed that I condemn the use of Indian corn in its various forms of 
mush, hominy, bread, or pudding as an article of diet; far from it. 
But, containing, as it does, a large proportion of starch and fatty 
matter, rather a small proportion of the nutrient principle, and quite 
a deficiency of the inorganic or earthy constituents, I consider it 
as valuable, as a light diet, for heat-sustaining purposes only, and 
therefore a desirable adjunct to other food, containing more nutri- 
ment and a due proportion of the earthy constituents. 

"As an example or illustration of the want of the nutrient prin- 
ciple in corn or corn-meal, I may here allude to the effects I have 
seen in the West Indies, where, in a dearth of the ordinary pro- 
visions on which prisoners were fed, corn-meal was substituted; 
corn-meal and salted herrings, fish, etc., constituting their food. 
Now, the effect was that all the prisoners lost their natural strength ; 
at the same time they became fat and bloated, inclining to dropsy. 
And this was not the effect of incarceration ; for the prisoners were 
engaged in road-making, trimming fences, etc., — consequently, in a 
healthy and exhilarating employment. 

" In reference to our domesticated animals, it may be asked, Why 
is corn so useful as an article of food to animals generally, — horses, 
hogs, sheep, etc. ? I have already shown that the overplus of the 
calorifacient food, after what may be required for sustaining the 
temperature, is stored away in the form of fat. Now, if we instance 
the horse, corn is generally, if not always, given as an adjunct to 
his more usual food, — hay. And we find by an analysis that grass 



THE TEETH AND THE IB DISEASES. 249 

or hay contains not only the nutrient principle, but the inorganic 
constituents required in the formation of bone, etc. 
''One hundred parts of dry hay contain — 

Carbon 45-8 

Hydrogen 50 

Oxygen 387 

Nitrogen* 15 

Ashesf 9 

100- 

"Thus, the hay gives to the animal strength in bone and muscle, 
while the corn supplies additional heat-sustaining properties, and 
lays by, in the form of fat, the overplus as a reserve. The harder 
the horse is worked, the more corn he can bear ; the great propor- 
tion of the carbon being carried off by the lungs, and the hydrogen 
and oxygen, as water, in exhalation and perspiration. But if the 
same quantity is given to a horse at rest, it overloads him with 
fat, which in his case accumulates more internally, or around the 
internal organs, and will, in course of time, induce disease; while in 
the pig, under similar circumstances, the fat is laid on externally, if 
I may so speak, giving the rich fat pork of our markets. And here 
I would again remark that no farmer would consider it necessary 
or essential to give corn to a young colt or horse, until required to 
work ; nay, so careful is nature in appropriating just so much and 
no more of any constituent that may be required, that the food of 
the young horse should be more nutritious than heat-sustaining, 
and that there shall be no superfluity to store away fat, we find by 
analysis that the milk of the mare has little or no butter — in fact, 
only traces of it — in its composition. J What a lesson in the animal 
economy is here given, and what a practical illustration of the re- 
quirements of the young of that and other animals ! 

" Again, it may be contended that among the beautiful children 
we see on every hand, there is no want of those who are fat and 

* Fifteen pounds of such hay, containing oz. 3 095 of nitrogen. 

f These ashes having a good proportion of lime. 

% Analysis of mare's milk : 

Water . 896 3 

Butter traces. 

Casein 16 2 

Sugar of milk, extractive matters, and fixed salts 87-5 

1000- 



250 ORAL DISEASES AND SURGERY. 

hearty. It is not fat we want; it is bone and muscle, with so much 
fat only as shall give firmness to the flesh and plumpness to the 
figure. Fat, although it enters intimately into union with the other 
component parts of bone and muscle, cannot be transformed either 
into the inorganic constituents of bone or teeth, or into muscular 
fibre. These must be contained in the food consumed, in the first 
place, and thence transferred to the blood. 

"How necessary, then, how important it is, if we expect to give 
strength and vigor to the constitution, that the food, in the first 
years of infancy and childhood, when the formative process is going 
on, should receive some further attention than has hitherto been 
given to it! and if our youth. — if our young females have hitherto 
been deprived of the necessary constituents for the full development 
of every portion of the body, — can we wonder that a woman should 
be the delicate and fragile being she is, or that by the decay which 
assails the teeth in early life she should be deprived of an orna- 
ment of so much value ? If this state of things can be altered, — if 
the physical constitution of woman in America can be saved from 
further degeneracy, — a purpose may be effected of consequence 
even in a national point of view; for it is to the healthy and vigor- 
ous constitution of woman that we must look for a race of hardy, 
vigorous, and enterprising freemen. 

"In conclusion, I would briefly state that this is a matter in 
which professional aid can avail little ; it lies at the door and must 
be the work of parents generally. It is for them to understand the 
great value to be attached to the food on which their children sub- 
sist, — that it shall be wholesome and nutritious, and abounding in 
the earthy compounds so absolutely necessary to their proper de- 
velopment. If the chief articles of food have hitherto consisted of 
compounds made of superfine flour, corn-meal, and the fat of meat, 
let there be substituted in their stead bran-bread, milk, eggs, the 
lean of meat, and potatoes; let more attention be given to the nu- 
trient quality of the food ; let there be no deficiency of those articles 
containing the earthy material, that the bones and teeth shall not 
be deficient in those constituents so necessary in their composition 
and structure ; and I should be inclined to hope that the evils which 
now exist will be lessened, and the physical organization of suc- 
ceeding generations be equal to that of any nation upon earth." 

From these hereditary and primal associations of dental caries we 
may now feel ourselves prepared to pass to local considerations ; 



THE TEETH AND THEIR DISEASES. 251 

and this brings us to the second of our premises, — namely, the shape 
of the teeth, their relation to each other, and their self-cleansing 
features. 

Fig. 59. — Superior Dental Arch. 




Fig. 60. — Superior Dental Arch. 




On examining the two arches, Figs. 59 and 60, the observer will 
instantly be struck with the decided difference presented. In the 
first, Fig. 59, is represented a denture which, mechanically speak- 
ing, may be pronounced perfect, every tooth having a harmonious 
relation with its fellow, and each individual tooth being perfect in 
itself. 



252 ORAL DISEASES AND SURGERY. 

In the second of the diagrams, Fig. 60, the artist has exhibited 
imperfections which, in truthfulness to nature, have been extended 
to every individual tooth, even to the crowding and wedging of 
them which are so frequently to be seen. Examining the molar teeth, 
the grinding faces are seen more or less pitted. These sulci are 
generally found uncovered at some point by enamel, an imperfection 
so common as to render these less resistive than their fellows. 
Hence caries is most frequent in this class. Particularly is this 
the case with the dentes sapientise, an operculum of gum being 
too often found an added cause of offense. To write any exact 
description of the irregularities of the faces of the molar teeth would 
be impossible, owing to the diversified aspects presenting them- 
selves. Sometimes such sulci are double, crossing each other at 
right angles. Frequently a single depression will separate the face 
into two principal cusps, and. running over the side, will terminate 
in a pit. Still again a single deep sulcus will occupy the very centre 
of the grinding face, the four cusps being more or less associated 
and ranged around it, ring fashion. In still other cases, a multitude 
of pits will cover the surface : on a single face I have counted as 
many as fifteen. 

The bicuspidati, for a similar reason, are markedly subject to be 
attacked. These teeth not only decay from their cutting face, but, 
because of a peculiar flatness characteristic of their proximal sur- 
faces, are more frequently attacked upon the sides than even upon 
the grinding surface above. 

The next in the order of liability are the incisors of the upper 
jaw. Observation of the diagram exhibits a flatness on the pala- 
tine face of these teeth, which in many instances falls into a positive 
sulcus. These pits it is impossible to keep clean : hence an antagon- 
ism which results in caries. The surface of these teeth most liable, 
however, to suffer from caries, is the proximal. This in many 
instances finds explanation in the constant abrasion here going on as 
the result of motion produced by the act of mastication, the enamel 
being literally worn or cracked away. In other instances, a species 
of pocket-like flatness is found near the necks, in which is lodged and 
retained the debris of diet. In still other instances, the dentine 
becomes deprived of its protecting enamel as the result of lateral 
pressure, such pressure being increased with the development of each 
new tooth ; this applies most particularly when the relation of ap- 
proximal contact is a limited one and not diffused over the face of 
the tooth at large. 



THE TEETH AND THEIR DISEASES. 253 

The inferior incisors and cuspidati are the teeth least disposed to 
decay. An explanation of such exception seems found in the shape 
of these organs and in their being fully surrounded by an antiseptic 
saliva. 

The wisdom teeth, universally viewed as being most predisposed 
to caries, derive such tendency from a twofold direction. Developing 
at a period when the formative force is losing vigor, these teeth 
are commonly deficient in the amount of that inorganic mate- 
rial which constitutes what might be called the mechanical resist- 
ance of the dental organs : in structure they are found, comparatively 
speaking, loose, while their general resistive power is low; they 
might, indeed, be likened to the osteophytes which form after bone 
operations, and which represent so imperfectly the tissue replaced, 
being found unable to resist antagonisms not at all injurious to 
properly-formed tissue. Again, as a local signification is concerned, 
these teeth, making their appearance at a period when all the other 
teeth are formed, find so little room in the arch as to render the 
process of eruption difficult, slow, and in some cases impossible: 
hence not only is a chronic morbidity engendered, but the face of 
the tooth is in many instances so long overlaid by an unabsorbed 
operculum (see diagram) that a perfect pocket exists, constantly 
rilled by ingesta. 

Condition 3. Constitutional Relations. — This is the purely medi- 
cal aspect of the question : it considers the varying changes in the 
individual as manifested in the changes of dental health, — whether 
such relation resides in altered nutrition of the organs or in the 
production of adverse associated expressions. An example is fur- 
nished in the condition of utero-gestation, a second in dyspepsia, a 
third in the anaemic diseases. 

The common proverb, " for every child, a tooth," has passed into 
general acceptation: statistics demonstrate that women lose their 
teeth in a twofold proportion to men, and that child-bearing women 
lose them in a threefold proportion to single women. Teeth which, up 
to a period of pregnancy, never required attention, will, in some in- 
dividuals, be attacked by a malignancy of carious action that shall 
quickly destroy a whole denture ; such caries having the twofold 
signification of a perverted nutrition and antagonistic local action. 

An all-important question here presenting itself is the cure. To 
esteem this as residing in plugs of gold, and to so practice, is to find 
one's self resting upon a staff of reed. The matter, primarily, is 



254 ORAL DISEASES AND SURGERY. 

solely one of nutrition ; not that necessarily phosphate of lime or 
other special material is demanded; the patient may have of such 
agents quite enough, both for teeth and foetus ; but the presence 
of agents of nutrition is not nutrition. Repair in living tissues 
resides in that function, as expressed by the physiologist, "by which 
nutritive matter, already elaborated by the various organic actions, 
loses its own nature and assumes that of the different living tissues, 
to repair their losses and support their strength." Here lies the indi- 
cation : it is, to correct the morning sickness which compels the 
stomach to refuse its food ; to keep cleansed an alimentary canal 
which, because of perverted secretions, is denied the office of its lac- 
teals, the whole economy thereby, Tantalus-like, being starved, even 
with plenty around ; it is to antagonize the perversions of appetite, 
which, refusing proper pabulum, craves substances injurious to the 
health at large ; it is to control nervous irregularities. To express 
the requirements in one sentence, it is to secure, and to preserve to 
the system, that assimilative force through which it may be enabled 
to add to its ordinary functional work the new labor demanded. 

Dyspepsia and anaemia, as causes of dental caries, have the same 
general constitutional signification as found in the condition just 
referred to. To enter into a discussion of these relations would, as 
is seen, carry us necessarily over the grounds of general medicine, — 
a domain with which it has been taken for granted the reader is 
familiar. 

Condition 4. Character of Agents in Contact with the Teeth. — 
The idea, as commonly held, that caries of the teeth depends exclu- 
sively on the existence of free acids in the oral cavity, is, to the 
mind and experience of the writer, a proposition which needs but 
little correct observation to limit it to very circumscribed boundaries. 
If any one hundred mouths be taken, having in them carious teeth, 
and the ordinary test by litmus-paper be made, four-fifths of them 
will be found neutral, if not alkaline. Alkalinity we would infer, 
then, to be a more common association of caries than acids; and of 
the truth of such position experiment will show that there can be 
little doubt. It is, however, a truth that the presence of any 
alkali may result in the formation of an eroding acid in a depression 
or sulcus, and it does this precisely as the same effect results in 
decaying woody fibre, — namely, by enabling substances to absorb 
oxygen which do not in themselves possess such power, or possess 
it to a very limited extent. Thus, perhaps in every mouth in which 



THE TEETH AND THEIR DISEASES. 255 

the fluids are alkaline, carbonic acid will be found in the debris of 
decaying teeth. 

Mucous Deposits. — Every one who has occasion to make observa- 
tions in the mouth has met most frequently with that condition of 
the mucoid secretion in which this fluid is glairy and tenacious, 
alkaline to the test, and not unfrequently offensive in odor, — a con- 
dition universally associated, when a habit, with dental caries, and, 
indeed, with general dyscrasia. Teeth in such a mouth are univer- 
sally covered with a film, and this so persistent that the ordinary 
use of the brush fails to disperse it, while the common dentifrices 
have alone the signification of a temporary good. 

Teeth so diseased find relief alone in acids, not only locally 
employed, but internally administered. A system secreting such 
mucus may be said to labor under the dyscrasia of super-alkaline 
poisoning, the agent having its point of exhibition most markedly 
in the mouth. It is really the condition of oral typh fever, — a 
typhoid condition expressing itself in this particular secretion, pre- 
cisely as in other instances accident might have directed it to the 
degeneration of the glands of Peyer or of the liver. A poison is in 
the blood, and by means of the circulation is diffused throughout 
every part of the system ; that it expends its force most markedly 
on certain parts is not unlike the expression of disease in general. 
If the blood of a patient laboring under this typh condition be 
examined under a microscope, it will be found that the normally- 
shaped red disks are diminished in number as compared with what 
are known to the pathologist as " the melanosed" corpuscles ; that is 
to say, as expressed by Chambers, "the dying or dead disks, shriv- 
eled and small, of a dark color, with black specks in them, and with 
gimped edges." 

But what is this typh poison, it may be asked? Unfortunately, 
the nature and scope of the present volume limit an answer to the 
simple elements of one of the most interesting questions in medicine. 
By typh poison is meant the existence in the blood of a super-alka- 
linity, which tends to dissolve the blood-corpuscles and to defeat the 
ends of tissue-metamorphosis. , This poison, according to its quan- 
tum, depresses to death, as seen too often in cases of typhoid fever, 
or it may expend itself in a simple deranged vitality, as witnessed 
in the stringy mucus now under consideration. How this poison 
enters the system, necessarily provokes much discussion. That 
one of its inroads, however, is by the stomach, is not to be doubted, 
seeing that in epidemic typhoid fever an emetic at the beginning of 



256 ORAL DISEASES AND SURGERY. 

an attack seldom fails to lessen the force and extent of the impression, 
such emetic seeming to act mechanically by emptying the stomach, 
thus preventing all the poison which had been received into that 
viscus from being taken up ; while still again it is observed that 
during the prevalence of such epidemics, those who smoke and 
chew tobacco, and thus eject their saliva, are least apt to be attacked. 

That, however, the typh poison may be generated from within, is 
scarcely to be doubted. In such chronic cases as associate with dental 
caries, this is the direction, no doubt, of the production ; and yet the 
condition may reside in a subacidity, the alkalinity being what 
might in proper health be normal, but which is in excess from the 
deficiency of a neutralizing acid. Unable, however, to devote a 
greater space to the consideration of a question well worthy a chapter 
in itself, we leave the subject with this hasty glance, extracting the 
deduction that the prophylaxis of caries in this direction is found in 
the free use of acids. If to the mind of any one this may need con- 
firmation, let a deduction be drawn from any two cases of ordinary 
typhoid fever, — one being treated with alkaline medicines, the other 
with acids. In seven cases out of ten, the patients treated exclu- 
sively with the first will die ; seven out of ten treated with acids 
will recover.* 

As a systemic medicament, let, therefore, the following be pre- 
scribed : 

R. — Acidi hydrochlorici diluti, gtt. x; 
Syrupi, 5ss; 
Aqua3, 3j. M. 

S. — To be repeated from one to three times a day, as may seem 
required ; or it might be that even five drops of the acid would be 
found sufficient for the requirements. In cases of typhoid fever, I 
have administered as many as twenty-five drops as a dose, repeated 
every three hours for two weeks. 

Conjoined with the acid it will be found serviceable to employ the 
quinias sulphas, — a grain pill once or twice a day, according to the 
length of time it is proposed to continue the medicine. A very good 
plan is to direct thirty pills : 

R. — Quinise sulphatis, gr. xxx; 
Extracti gentianae, 3j- M: 

* This assertion is founded on observations made in daily attendance on 
quite a number of patients during an epidemic lasting nine months. 



THE TEETH AND THEIR DISEASES. 257 

To be divided into pills No. xxx ; one or more to be taken each 
day. 

Asa mouth-wash, the following combination will be found appli- 
cable : 

B. — Tincturae capsici composite, 3ij 5 
Aquae Colonise, £ ij ; 
Spiritus vini, ^ij ; 
Tincturae quillai, giss ; 
Tincturae gentianae compositae, §j ; 
Acidi acetici diluti, §ss; 
Acidi carbolici fluidi, ^lij. M. 
S. — To be used by saturating a tooth-brush which has been first 
dipped into water. 

Where much offensiveness in odor is associated with this in- 
spissated mucus, it may be necessary to use a gargle of the per- 
manganate of potassa or of the aqua chlorinata. For the former, 
a very good proportion would be as follows : 

B. — Potassae permanganatis, gr. xv; 
Aquae, ^viij. M. 
S. — Use as required. 

Still another most excellent preparation for such disinfection is 
the phenate of soda ; indeed, by many, preference is given to this 
article above most others. It is used diluted with water in such 
proportions as seem demanded to meet the indication of the special 
cases prescribed for, — ordinarily one part of the phenate to ten parts 
of water. 

Acid Secretions. — That the common oral fluids are occasionally 
to be found of an acidity sufficiently strong to be injurious to the 
limy structure of the teeth is not, of course, to be denied. When 
such state exists, it is easily to be demonstrated by furnishing the 
patient with a few strips of litmus-paper, which are to be wet 
with the fluids of the mouth at varying periods of the twenty- 
four hours. In the morning, immediately upon rising and before 
taking fluids, is the test perhaps of most signification. If such test 
reddens the paper for a series of mornings, an antacid indication 
would seem to be fairly established, and local prescriptions, some- 
thing in combination like the following, may be directed : 

It 



258 ORAL DISEASES AND SURGERY. 

R. — Aquse calcis, %iv • 
Tincturae cinchonae, 
Tincturae pyrethri, aa gj ; 
Tincturae quillai, £ij ; 
Potassae chloratis, 3j ; 
Aqu83 chlorinatae, 5U ; 
Spiritus vini, gj ; 
Tincturae gaultheriae, q. s. M. 
S. — To be used with the tooth-brush. 

Or, 

R. — Potassae chloratis, ^ss ; 
Aquae, giij ; 

Tincturae capsici compositae, 3\j ; 
Aquae Colon iae, gj ; 
Tincturae quillai, ^iss ; 
Olei limonis, vel verbena, vel 
gaultheriae, q. s. M. 
S. — To be used with the brush. 

If it prove more convenient to employ powders, something like 
the following will be found to answer the required purpose : 

R.— Cretae praeparatae, 

Iridis Florentinae pulveris, 

Ossis sepiae pulveris, 3ij ; 

Olei limonis, q. s. M. 
Or, 

R. — Cinchonae rubrse pulveris, 3tj ; 

Capsici pulveris, gr. x ; 

Potassae chloratis pulveris, Jj ; 

Pulveris aromatici, 3ij ; 

Saponis castiliensis pulveris, gj ; 

Magnesiae carbonatis, ^ss ; 

Iridis Florentinae pulveris, Jj. M. 

Conjoined with the local antacids, attention is likewise demanded 
to the functional, or it may be organic, conditions producing the 
acids. Different derangements of the general health will exhibit 
different acids. Thus, in one mouth will be found the uric, in an- 
other the lactic, in still another the nitrous, etc. These productions 
have their constitutional meaning and indications. As examples in 






THE TEETH AND THEIR DISEASES. 259 

such directions of practice, the presence of uric acid in the mouth, 
as in the urine, would be most apt to be found associated with 
deficiency in respiratory action and with circulatory sluggishness. 
Lactic acid in the saliva would almost certainly indicate the con- 
dition of diabetes, although diabetes does not necessarily yield lactic 
acid to the saliva. Formic and acetic acids found continuously in 
certain mouths have been made quickly to disappear through treat- 
ment directed to an existing leukaemia. 

Parasites. — The parasitic theory of dental caries holds good only 
as fungi, animal or vegetable, are added causes of deterioration. 
Lodged in a cavity of a tooth of soft structure, these no doubt act 
the part of destructive agents, by insinuating themselves into the 
tubular and intertubular spaces, interfering with and counter- 
balancing the resistive efforts of dentinal consolidation, and serving 
as sponge-like bodies, to hold in contact with the parts agents alike 
injurious with themselves, lowering also the resistive vitality through 
an appropriation of nutritional pabulum. 

To destroy these fungi, few agents will be found more reliable 
than what is known as the dental carbolic acid soap. This soap 
should be used twice a . day, and particularly is not to be neglected 
on retiring for the night. Powders also serve an excellent purpose, 
removing the offense mechanically. Acid washes, as suggested, 
may also be prescribed. Dr. Aitkin, of Edinburgh, recommends 
the production in the mouth of sulphurous acid through a solution 
of the sodae sulphis : 

B. — Sodas sulphitis, $j ; 
Aquae, fgj. 

In proportion as the secretions are acid, the salt is decomposed, 
the sulphurous acid being set free. This disengaged acid will, it is 
affirmed, destroy the parasites in twenty-four hours. 

In the case of a family of children where parasitic offense was 
associated most markedly with putrescent caries, a change quite 
wonderful in its character was produced by alternations of acid 
and alkaline washes. Either of these, by itself, failed utterly in 
any satisfactory result. I was led to infer, therefore, that two 
orders of fungi harmoniously existed, — the one impressible by acids, 
the other by alkalies; and the result of the treatment certainly seemed 
to verify the conclusion. The fluids of all the mouths were neutral. 
The Protococcus dentales, very minute organisms, are referred to by 
microscopists as being most frequently found in carious dentine, 



260 ORAL DISEASES AND SURGERY. 

although it is not at all uncommon to meet in profusion the spi- 
rilla, arncebas, monads, etc. 

The following examinations, made by Dr. Joseph G. Richardson 
(author of the " Handbook of Medical Microscopy'') on the first five 
patients coming into the office of the author after completion of the 
required arrangements, will be read with interest : 

Specimen I. — Patient, young lady. Mouth remarkably healthy- 
looking ; gums hard ; had lost no teeth ; cavities very few in num- 
ber ; oral fluids neutral; teeth clean; no tartar or other collections, 
specimen examined being a particle of carious dentine. Examination 
with a one-twenty-fifth-inch objective, giving with the No. 1 eye- 
piece a power of about twelve hundred diameters, showed multi- 
tudes of bacteria and short leptothrix filaments, all, however, quite 
motionless. 

Specimen II. — Old lady. Teeth breaking down in every direc- 
tion ; diffused collection of pasty debris ; gums soft and unhealthy- 
looking ; epithelial cancer involving left half of lower lip, and pass- 
ing around the commissure to upper lip ; patient very deficient in 
vital force. Specimen examined being debris from the side of an 
inferior cuspis, against which rested the disease. Exhibited long 
bundles of leptothrix filaments, consisting of from five to fifty my- 
celial threads, each about one-ten-thousandth of an inch in diameter, 
and sometimes attaining the enormous length of one-tenth of an 
inch. These fibrous-looking bundles were interlaced and imbedded 
in a large amount of granular stroma, apparently composed in great 
measure of bacteria and bacteridia, as many of the former could be 
seen in very active movement around the margins and in the inter- 
stices of the masses. 

Specimen III. — Patient, young lady. Mouth in the highest 
degree healthy-looking ; had lost no teeth ; very few cavities, and 
these all filled beautifully and perfectly with gold ; fluids neutral ; 
no tartar. Specimen examined being a mere particle of debris found 
between the inferior central incisors. Showed also great numbers 
of comparatively short leptothrix filaments, among whose interstices 
floated, in molecular (Brunonian) movement, multitudes of bacte- 
ridia and nearly motionless bacteria. A few of these minute organ- 
isms manifested voluntary action, which continued in certain 
instances for at least thirty-six hours after removal from their parent 
mouth and immersion into the three-quarter per cent, salt solution. 

Specimen IY. — Boy with hare-lip. Oral fluids alkaline, stringy, 
and tenacious. Specimen examined being carious dentine from a 



THE TEETH AND THEIR DISEASES. 261 

lower molar. Showed immense numbers of bacteria, short leptothrix 
filaments, chains of spores, and occasionally a specimen of spiril- 
lum. These fungi were especially abundant around the margins of 
dentine scraped from the cavity; and, as they were not accompanied 
by salivary leucocytes, it is probable that they did not proceed from 
the saliva, but had developed within the tooth. 

Specimen V. — A molar tooth with a large cavity in its side was 
extracted from the mouth of fifth patient, a scrofulous lady, with 
most unpromising teeth, and, after being split open, was subjected 
to examination. The branch of the cavity, extending into one of 
the fangs, was filled with a soft spongy mass, which, under the 
microscope, was seen to be composed of long interlacing filaments 
of leptothrix buccalis, such as were found in Specimen IT., and to be 
swarming with bacteria. 

A portion of the cavity at the edge of the split surface was scraped 
clean, and thin sections of the still firm but diseased dentine were 
made with a strong sharp knife. These fragments, when examined 
with a power of twelve hundred, were seen to be associated with 
many bacteria and filaments of leptothrix, the latter of which seemed 
in several instances to occupy the dentinal tubules and to project 
from their fractured extremities. Although being then, of course, 
without movement, it was difficult to say with absolute certainty 
that the structureless fibre-like bodies were actually portions of the 
vegetable growth. 

Electro-chemical Relations. — Every observer must have remarked 
how much more common is caries to moist than to dry mouths, and 
how much more common is the failure of an approximal plug at the 
base-wall than elsewhere about its circumference. These conditions 
have been discussed by Mr. Kencely Bridgman, L.D.S., in a paper 
on the electro-chemical action of metallic substances upon the teeth, 
with an exhibition of experimental research and learning which 
commends his views to the most respectful consideration. 

" While investigating," says this observer, "the action of voltaic 
electricity upon organic compounds, it was observed that all defects 
of metallic fillings in the teeth could be represented by results ob- 
tained out of the mouth. That decay might be, and probably was, 
a chemical action, every one was quite ready to admit; but how it 
could be electro-chemical did not appear to be in the slightest de- 
gree comprehended. The immediate effects of chemical action could 
easily be recognized as such ; but the previous electric condition 
giving rise to this chemical action required a somewhat intimate 



262 ORAL DISEASES AND SURGERY. 

acquaintance with the laws of physical forces to render its presence 
appreciable ; and, consequently, the only valuable portion of the theory 
has hitherto been left in abeyance." 

A basal experiment upon which the deductions of Mr. Bridgman 
are founded is as follows : 

"A rod of absolutely pure zinc, three and a quarter inches long, 
after being thoroughly amalgamated with fresh distilled mercury 
and drained, and weighing four hundred and eighty-seven grains, 
was placed half its length in cold dilute sulphuric acid, and the 
other half exposed to the atmosphere, in the same position as the 
ordinary plates of a battery. In a very short time bubbles of 
hydrogen made their appearance over the whole surface exposed 
to the acid, and after forty-eight hours the metal was found to have 
lost upwards of ten grains in weight. This loss, however, was by 
far the least important part of the results obtained. The immersed 
portion of the metal had not been acted upon uniformly over its 
whole surface ; but the action had been greatest at the surface of the 
liquid. At the same time the exposed portion had become covered 
with patches of crystalline sulphate of zinc, high and dry upon the 
projecting portion of the metal. Therefore, not only had chemical 
action been exerted between the metal and the acid and the water 
decomposed, but there was the additional evidence that the metal 
itself had become polarized." 

Associated with this first is the repetition by Faraday, copper 
being used instead of the amalgamated zinc, the color of the crystals 
and the coloring of the acid affording more conspicuous evidence of 
the results produced. 

"A piece of stout copper wire being placed similarly in acid, the 
latter very soon gave signs, by the coloring it received, of the copper 
commencing to undergo solution ; and, after having been suffered to 
remain undisturbed for twenty days, it presented the appearance 
above the acid of a bushy rod, the portion exposed to the atmos- 
phere becoming coated with a layer of minute and beautiful crystals 
of sulphate of copper, extending from near the top to within three- 
sixteenths of an inch of the liquid. At this intermediate portion a 
greater amount of chemical action had been induced, corroding the 
wire about half-way through and forming a neck tapering upwards." 

That the action which arises between the metal and the acid is 
due to polarization is evidenced by the following proceeding: "A 
similar piece of copper wire, wholly submerged in the acid, so as to 
entirely exclude any portion of the metal from coming in contact 



THE TEETH AND THEIR DISEASES. 263 

with the air, has remained for many months without imparting the 
slightest tinge of color to the liquid ; but on suffering the fluid to 
evaporate, so as to bring the upper end of the metal near to its 
surface, the instant the slightest portion becomes exposed to the 
atmosphere chemical action immediately commences." There is 
thus, where no sufficient normal affinity exists between the metal and 
the liquid to effect the decomposition of water, a power imparted, by 
the metal being polarized by the atmosphere, which renders it then 
capable of accomplishing it. 

" The atmosphere," says Mr. Bridgman, "in its normal state being 
electro-positive, renders, by a well-known law of induction, bodies 
opposed to it electro-negative. The exposed end of the copper is, 
therefore, thus rendered electro-negative, and the acid, by the same 
rule, being electro-negative also, the immersed end of the metal be- 
comes electro-positive. It is an established rule that bodies to be 
electro-decomposed must first be rendered electro-positive; and it 
is also apart of the same rule that bodies receiving an addition of 
matter must first be made electro-negative. Hence the exposed end of 
the metal has become negative and received the crystallization, while 
the immersed portion, being positive, has been acted upon accordingly. 

" The appearance, however, of the crystallization upon what was 
at first the dry end of the metal requires particular attention. It is 
one of the special effects of electrolytic action that fluids pass to, and 
accumulate at, the negative pole. Obeying this law, the acid imme- 
diately begins to ascend and spread itself over the surface of the 
unimmersed end of the metal. But now we have another special 
provision, which demands the most careful and attentive considera- 
tion, as it constitutes the first step in the resulting chemical action. 

" One metal placed in two dissimilar fluids, as the air and the 
acids, acquires the same condition that two dissimilar metals, or 
one metal non-homogeneous, assume when exposed to the air : each 
has become polarized, and rendered amenable to chemical action. 
Water, being a compound of gases chemically combined, can have 
its gases uncombined only by equal degree of force being antago- 
nistic to them; and consequently the decomposition of water must 
be preceded by some other arrangement. Now, the atmosphere, being 
only a mixture of gases, or gases merely in a state of mechanical 
admixture, which admits of their being readily separated on the 
slightest interference, supplies the initiatory steps by which de- 
composition can be effected. 

" The first immediate effect upon a polarized metal is to drive 



264 ORAL DISEASES AND SURGERY. 

the oxygen of the atmosphere to the positive end. Its combination 
with the metal, in oxidating or rusting it, is a chemical action deter- 
mined by the electro-polar condition ; and it has been established by 
Faraday and others that this chemical union is invariably accom- 
panied by a development of electricity, which in its turn can be 
made to produce electro-chemical results of an equal degree in 
another direction. 

" The greater amount of action taking place at the neck of the 
copper wire will now be readily comprehended. The oxygen of the 
atmosphere has been driven toward the positive end of the metal ; 
but its progress has been arrested by the acid surrounding it. The 
thin fibres, however, rising from its surface, being soon saturated 
with the oxygen, and presenting the latter in its most favorable 
form for acting upon the metal, facilitate its oxidation, and con- 
sequently accelerate its solution, and render the ascending acid 
saturated and ready for at once becoming a crystalline deposit, while 
little or no solution has been effected in the acid below. 

" It must be kept in mind that an electric state is not a fixity, but 
is relative, and depending upon attendant circumstances. Thus, if 
the copper wire had been subsequently inverted, the immersed end, 
which is now positive, would then have been rendered negative, and 
vice versa ; or had the acid at any time been filled up to the top of 
the tube, the exposed portion only, however small that might be, 
would have remained negative, the surface of the liquid determining 
the line of demarkation between them. 

" Let us now apply these facts to the mouth. The external epi- 
thelial layer of the gum is constantly throwing off its worn-out 
cells, and by this wasting process it determines its electro-positive 
state, while the crown of the tooth, as a continuation of the epider- 
mal layer, partakes of the like condition. Were the teeth wholly 
and constantly submerged, and protected from the air, it is probable 
that, like the copper wire beneath the acid, they too might remain 
intact. But as the air is constantly passing into the mouth, or even 
through it in the act of breathing, they are thus, having one end 
exposed to the air and the other to the fluid moistening the gum, 
subject to the same polarizing influence as the metals. 

" The negative portion of the polarized tooth being represented 
by the portion of the wire exposed to the atmosphere, it will be at 
once comprehended why tartar accumulates upon certain parts only 
of the teeth, and how it is enabled to creep over the surface and 
adhere with tenacity. 



THE TEETH AND THEIR DISEASES. 265 

"In the case of the partly-submerged wire it has been shown that 
the principal amount of electro-chemical action takes place near the 
surface of the fluid, this point determining the line of demarkation. 
Hence in the mouth this line may be taken as the existing free edge 
of the gums. The moisture accumulating here, in the event of any 
electro-chemical action taking place, it would necessarily be imme- 
diately above that line, and consequently the substance of the tooth 
directly above the gum would be attacked. We see this actually 
taking place in the peculiar decays so common at the exterior or 
anterior basal area of the molars, and also on the same part of the 
upper incisors. 

"In the interstitial divisions, the moisture accumulates between 
the teeth by capillary attraction, and in connection with this we 
have approximal decay as one of the commonest forms occurring. 
The oxygen is attracted to the part, and produces the acid so in- 
variably present, while, by electrolysis, the lime is abstracted and 
removed to another part, or carried away in solution. By such 
electrolysis," Mr. Bridgman thinks, "every other phase and phe- 
nomenon of decay is to be traced and explained." 

Yiewing the matter strictly from the standpoint of a chemist, our 
author has overlooked vital resistive force. We trust we have, 
however, completed this portion of his subject for him, and thus 
afforded him a required support in the chemico-vital aspect of his 
subject in which his foundation seems lacking. 

We may here follow Mr. Bridgman in his consideration of filling- 
materials. 

"In a prize essay," he says, "I have shown that an amalgam 
filling in the side of a tooth having one edge near the gum generates 
acid at the latter point. This is due to polarization. A body of 
metal having its two ends or opposite sides exposed, under different 
circumstances, becomes polar, and in proportion as there is any 
substance to be acted upon by oxygen, so is the amount of chemical 
action regulated. Thus, a metallic plug in an approximal cavity, 
or in the external basal area of the molars, will have the cervical 
edge continually wet, while the upper part may be comparatively 
dry; and hence will be assumed the two conditions as represented by 
the intermediate and exposed portion of the wire. It has often been 
lamented that, however carefully and well these fillings may have 
been done, there is the ever-recurring annoyance of finding, in a few 
years at the most, and not unfrequently in a few months, that the 
sides of the plugs and baso-caval surface have become defective ; 



2QQ ORAL DISEASES AXD SURGERY. 

showing that, although all the defects may have been removed in 
the first instance, the cause has been retained. 

"With the entire range of metals and metallic compounds, it may 
be taken as a fact that from gold to copper and zinc it is only a 
question of degree, for the one cause affects them all more or less. 
In respect to this, gold is unquestionably the best by very far, as 
being one of the least oxidizable ; but even with this, certain pre- 
cautions are essential to success. The one indispensable condition 
is that there shall be no lodgment for moisture at any point of its 
circumference. The edge of the plug must be made as perfect as 
possible, and no fissures communicating with it may be suffered to 
remain ; for, if there be, electro-chemical action will be certain to 
recommence. 

"With amalgams, this precaution is, if possible, even more impor- 
tant ; but with these there are other points requiring attention. The 
composition of amalgams is a subject which has never yet been 
systematically investigated, and those now in use differ considerably 
in character. 

" Zinc and copper, and their various alloys, with tin and silver, etc., 
form the hardest amalgams ; while gold, silver, palladium, and pla- 
tinum form only imperfect amalgams, which never acquire sufficient 
hardness to resist friction. In the latter, too, the mercury readily 
oxidizes and produces discoloration, while some of the former pass 
very quickly from oxidation to the acidifying stage, and thus soon 
reproduce the electro-chemical destruction of the dentine. 

"There is another and more serious objection still to be urged 
against some of the. more modern preparations. Amalgams hard- 
ening under a state of polarization assume, in some cases, a peculiar 
surface-crystallization, but almost invariably possess coarser crystals. 

"I have exhibited," says Mr. Bridgman, "two pieces of zinc which 
had been amalgamated and suffered to harden, — one under polariza- 
tion, the other without it. With the polarized surface the metal 
had acquired a considerable amount of crystallization of a peculiar 
character, projecting above the level of its surface, together with a 
somewhat coarsely crystalline texture without ; while that which 
had been allowed to harden without being polarized was much 
finer in texture, although distinctly crystalline. Two pieces of 
amalgam, treated in a similar manner, showed the same correspond- 
ing results. In addition, both the polarized metals exhibited more 
discoloration than the unpolarized ones, and all showed that amount 
of roughness inconsistent with a perfect filling." 



THE TEETH AND THEIR DISEASES. 267 

Having thus traced the defects of metallic fillings, Mr. Bridgman 
proceeds to consider whether the objections are insuperable. 

" There are two proceedings indicated," he remarks, " as being 
desirable. The one is to prevent polarization ; the other, to prevent 
the effects of polarization being reflected upon the dentine. The former 
is not by any means difficult, but it requires a thorough knowledge 
of the laws under which it takes place to adopt the provisions under 
all the different circumstances required. Insulation, however, is one 
of the means to be secured. This, too, is the end to be sought in 
protecting the dentine. Either gutta-percha, waxed tissue-paper, 
or allotropic sulphur — but, above all, the so-called os-stopping— 
forms an admirable lining for a cavity, where little success could be 
hoped for from an unprotected amalgam. It also compensates for 
the want of fineness in the texture of the metal." 

There is another point in connection with the electro-chemical 
action of metals upon the teeth discussed in the paper under consid- 
eration. Wherever a gold band comes in contact with the exposed 
dentine of a tooth, injury is commonly seen to ensue, and decay 
supervenes if the touched part be near the gum. This is assumed 
to be fully explained in the experiment with the copper wire. " The 
gold," says Mr. Bridgman, " may touch any part represented by the 
blue sulphate, but at the intermediate portion — that is, that portion' 
of the tooth just above the margin of the gum — it is fatal." 

Criticism on these deductions is anticipated in a recognition of 
the fact that the author considers special cases alone, and does not 
lay down a general rule. That he fairly exposes the condition of 
many mouths seems entirely beyond doubt ; and it must be ad- 
mitted that he has given a very satisfactory expression to the 
chemical aspect of the subject of dental caries. (See Denuda- 
tion.) 

Medicines and Articles of Food. — That medicines, even the nitro- 
muriatic acid so frequently prescribed as an hepatic alterative, and 
the muriated tincture of iron used by almost every practitioner as a 
tonic, are not such sources of offense to the dental organs as is gen- 
erally inferred, the author has come to be reasonably well satisfied 
Prescribing both combinations with much frequency in his clinic as 
well as private practice, he founds this conclusion on an extent of 
observation that would seem to render it entirely reliable. Not that 
the careless employment of such medicines is at all to be com- 
mended ; but the inference is meant to be conveyed that caries 
associated with the periods of such prescriptions has explana- 



268 ORAL DISEASES AND SURGERY. 

tion in the conditions prescribed for, rather than in the medicines 
prescribed. 

Acids are not best given through glass tubes, but, being sufficiently 
diluted, the draught, if such care be thought necessary, may be 
thrown into the back part of the mouth, and swallowed in a single 
muscular act, after which the mouth may be rinsed with water 
rendered slightly alkaline by the addition of a few drops of liquor 
arnmoniae. The system, however, which demands an acid medi- 
cation will seldom find its dental organs injured by the reception 
of a share. Chalk, in place of the ammonia water, is suggested by 
Dr. J. D. White, he asserting that in this article acid medicaments 
find their quickest and most reliable neutralization. 

Mercury, as a medicine, has no direct effect on the teeth, — its 
action having an intermediate signification; neither have any of the 
potash preparations as ordinarily administered. 

Sugar. — As usually employed, sugar is not to be considered an 
agent deleterious to the teeth, as locally it can only act through 
its conversion into acetous acid. A too free use of the agent, how- 
ever, by debilitating the digestive functions, indirectly affects these 
organs, in common with all other parts, by diminishing the resistive 
force, — in other words, through malnutrition. 

Vinegar, lemon-juice, the malic acid of apples, the tartaric of 
grapes, will, all of them, in varying extent, decompose tooth-struc- 
ture through affinity for the lime. "When, however, their action is 
thus injurious, the fact is easily recognizable by the patient in the 
loss of that polish noticeable on touching the organs with the tip of 
the tongue ; or in the presence of the feeling which is described by 
the expression, familiar to every person, of " the teeth being on 
edge." 

It is not, however, to be affirmed or maintained that any of these 
articles, when brought in contact with the teeth under the circum- 
stances of mastication, with their speedy dilution by the oral fluids 
— always proportioned to requirements — are sources of disease to 
the parts. Prudence in the use of such things is, nevertheless, to be 
recommended to every person having teeth of loose structure, — soft, 
chalky teeth. 

Of the dried fruits, raisins may, it seems to the author, be with 
most reason denied ; they do without doubt rapidly corrode the teeth, 
and are most tenacious in their lodgment. That it is necessary to 
proscribe their use, except in the case of children, is, however, at 
least debatable. 






THE TEETH AND THEIR DISEASES. 269 

The spiritus nitri dulcis, — a compound of the nitrate and carbonate 
of potassa, sulphuric acid, and alcohol, — freely used in the United 
States as a febrifuge, particularly with children, is credited with 
being a frequent cause of dental caries ; the diluted state in which 
the medicine is always administered, however, may lead this infer- 
ence to be received cum grano salts. 

Condition 5. The Absence of Mechanical Destructives, as sali- 
vary calculi, the bands of artificial denture, etc. See chapters on 
Salivary Calculus, and Dentures. 

Condition 6. Accidental Influences. — Under the sixth head 
reference may first be made to what may be termed the gymnastics 
of the teeth. These organs, like all others of the body, require to be 
used, and, when denied the exercise of their function, deterioration 
universally follows. Illustration of this is markedly exhibited in 
slop-fed cows, the teeth refused their accustomed task quickly be- 
coming carious and loosened ; also in the case of persons using alone 
one particular side of the dental arch, — the unused organs being soon 
enveloped in tartarized debris, and the gums becoming turgid and 
debased. This debasement is shown also in those who live on food 
which demands but little trituration. 

The practice indulged in by many persons of breaking the harder 
shell nuts with the teeth is most reprehensible, cracking and splitting 
the enamel, and thus exposing the more susceptible underlying den- 
tine, — or, even where such accidents do not occur, exciting through 
shock a species of chronic inflammation which lowers the resistive 
force of the tooth. 

" Dental operations," as remarked by Dr. J. Taft in his work on 
"Operative Dentistry," "performed at an improper time and in an 
improper manner, the vitality of the teeth being thus impaired, or a 
diseased condition being established, are to be esteemed as exciting 
causes of caries. Often from improper use of the file extensive 
inflammation of the dentine supervenes, which is sometimes fol- 
lowed by death of the tooth and by disease of the contiguous parts." 
Another cause enumerated in this volume is " sudden transition from 
one extreme of temperature to another." 

The employment of a variety of metals, as fillings, is objection- 
able. Particularly is it the case that amalgam and gold should 
not be used in conjunction. I think it will be found an exception 
where a healthy denture can be exhibited having these two articles 



270 ORAL DISEASES AND SURGERY. 

promiscuously related. This stricture also applies to the case of 
gold plates much alloyed with the meaner metals, as with silver or 
copper, particularly the latter. 

Cleanliness is an essential to a healthy denture. Teeth should 
be cleansed after every meal ; to this end a tooth-pick — always to 
be made of wood — is to be passed through the interspaces, and the 
mouth afterwards rinsed with water, or water to which have been 
added a few drops of alcohol or cologne. As a dentifrice, to be used 
when required, — which will, most likely, be once each day at least, 
— the following combination may be employed : 

R. — Ossis sepia? pulveris, ^ss; 
Cretse praeparata?, 3ij ? 
Coralli albi pulveris, ^ss; 
Iridis Florentine pulveris, Jj ; 
Carbonis ligni pulveris, 5j ; 
Lapidis pumicei pulveris, 3\j ; 
Olei limonis, q. s. 

In a mouth self-cleansing, however, where there is little tendency 
to the accumulation and retention of debris, it would not, of course, 
be found necessary to have such excess of cutting ingredients. A 
modification of the prescription might therefore be made : 

R. — Cretse prseparatse, 3U ; 
Ossis sepia? pulveris, ^ss ; 
Iridis Florentine pulveris, gj ; 
Cinchona? rubra? pulveris, 3j ; 
Saponis albi pulveris, 3U- M. 

In the treatment of any case of dental caries which may present 
itself, the careful practitioner first endeavors to satisfy himself of 
the causes, constitutional and local, influencing the diseased condi- 
tion ; of the constitutional causes, all, as must be inferred, affect the 
integrity of the teeth which are deteriorative to the system at large. 
Unhappily for the dental organism, primary unhealthy impressions 
made upon the teeth, while in their formative or pulpy state, are 
apt to influence more or less their character for life, just as certain of 
the exanthemata, — variola, for instance, — occurring at this period, 
are so apt to impress permanent pittings upon the enamel. 

Unhealthy parents, as has been suggested, cannot possibly beget 



THE TEETH AND THEIR DISEASES. 271 

healthy offspring. Here is a great primary antagonism. The 
teeth, however, are living and, consequently, changing bodies : par- 
ticularly is this true, physiologically, of young teeth. Constitutional 
treatment may thus do service even as every molecule of tooth- 
structure is concerned. Such treatment would of course be longer 
in receiving apparent response, as must be evident upon considering 
the relative low vitality of these organs, than treatment directed to 
the production of an impression on the soft parts, or on common 
bone; yet, because a tooth is an organized body, because it has 
innervation and circulation, such treatment, to a greater or less 
extent, must have its influence. 

A first indication calls, therefore, for the consideration of causes 
interfering with the proper vitality of any denture coming under 
observation. Whether deteriorated hereditarily or otherwise, duty 
to the patient demands such consideration of the case. 

We will suppose a trouble to be hereditary. Here, if we can find 
in a patient the observable existence or continuance of habits of 
functional irregularity, or of animal habits common to the parent 
and which are to be esteemed of deteriorating import, our first atten- 
tion is to be directed to a correction. The parent may have been 
specifically diseased, let us suppose, by his parent, and thus the bad 
teeth of both father and child lie in a venereal molecular impression. 
Here a predisposing cause would have come from and would be still 
residing in the transmitted condition. Granting, then, that such mole- 
cules, still living, are impressible, would not judgment direct a pri- 
mary treatment to the production of an impression in such direction ? 
I have treated many a child, for skin- and other diseases, where the 
affliction was a true hereditary venereal transmission, and I never 
thought of directing medication otherwise than in recognition of 
such a transmission ; and satisfied, as every medical man must be, 
that the circulatory fluid permeates tooth-structure, I treat vene- 
really deteriorated teeth on a common principle, and have found in 
the result that measure of success which has justified the conclu- 
sions. In other words, I have prolonged the life and health of such 
organs, just as are prolonged the life and health of the patient upon 
whose molecules is impressed the fiat of the tubercles of phthisis. 
Such a treatment consists, however, not necessarily in administer- 
ing specific or supposed specific remedies, but in viewing the system 
as laboring under depressing influences, either of a general or special 
local signification. This fact it is most important to recognize. 

A child, as we have studied, may have its molecules deteriorated 



272 ORAL DISEASES AND SURGERY. 

by a transmitted mercurial impression, or a parent may have been 
an inebriate, and thus have debased his child in himself. The 
results of an excessive venery may have been transmitted. A 
mother, from lack of nourishing material, may have degenerated her 
offspring. These causes of transmitted ills, the appreciable ones, I 
may say, are many : all must recognize them. 

Improper diet to the developing child, as we have so fully studied, 
is plainly enough a cause of bad teeth. The state of health of such 
a developing child has its influence ; indeed, so marked is this, that 
by an observation of teeth belonging to the various periods of life, 
one can easily trace constitutional variations ; for just as at different 
periods the functions of organic life were healthily or unhealthily 
performed, so we find the disturbances written in the character of 
the teeth belonging to the period. More expressive even than this 
is the fact that the deciduous teeth mark, in the progress of their 
development, the health of the mother. 

That the teeth, in their formative state, partake of the healthy or 
unhealthy condition of the system at large, all observers admit. 
But here, unfortunately, the matter has been left, most practitioners 
acting on the premise that such impressions are never to be altered. 
At such a conclusion it is impossible not to express surprise. "Who, 
in his own person or in the persons of friends, has not remarked the 
varying conditions of the health of the teeth ? Up to the age of 
sixteen I was myself a martyr to toothache ; yet about that period 
a change occurred, since which time I have had no trouble. Is it 
suggested that the teeth may have been filled? True, they have 
been ; but certain of the fillings came out years ago, and have never 
been replaced, yet the teeth are quite as good as those in which 
the operations remain. 

Similar instances exist in profusion, and yet the lesson seems 
unheeded. There is a constitutional treatment for the carious tooth, 
as there is for the carious maxilla, and from a common standpoint 
are the diseases of both to be viewed. It is not, of course, every 
case of a carious bone that demands systemic treatment, neither 
is it so with the teeth ; the source of offense in the one, as in the 
other, may be strictly local in its character ; but ill success must 
ever attend that practitioner who has not the inclination to look for a 
primary lesion outside of things strictly local in signification. 



Resume. — Integrity of the teeth depends on two general con- 
ditions : inherent vital resistive power, and the absence of irritating 






THE TEETH AND THEIB DISEASES. 273 

influences. A tooth may, in its vital relations, be just strong 
enough to resist external forces brought to bear against it, if in its 
construction there is no mechanical imperfection. It may, even 
with imperfections, be able to resist temporary injurious impres- 
sions. The vitality of a tooth can be elevated as the vitality of 
a lung is increased. The study of the vitality of a tooth, and the 
study of its adverse influences, is the study of vitality and the ex- 
pression of irritation anywhere. The treatment of dental caries is 
both medicinal and operative. 



18 



CHAPTER XL 

THE LOCAL TREATMENT OP DENTAL CARIES. 

Caries of a tooth differs surgically from caries of bone proper in 
the fact of a too common inability to repair by any effort of nature 
the injury done through the destructive influences of the disease. 
Not but what such repair is attempted, and indeed oftentimes suc- 
cessfully accomplished, as witnessed in tubular consolidation, where 
power sufficient exists to perfect the attempt, as seen in the process 
generally spoken of as vitrifaction or eburnification, a mode of natural 
cure and resistance which no mechanical operation, however success- 
fully performed, can equal. This process of secondary calcification, or 
eburnification, exhibits fully the inflammatory phenomena associated 
with dental caries, for not otherwise than as circulatory expressions 
is it possible to explain the phenomena : it is, in every particular, 
a modified repetition of the ordinary lymph exudation and circum- 
vallation seen in abscess, either of bone or soft parts. 

A tooth attacked in any part by caries expresses the stages and 
steps of the inflammatory process, inasmuch as at the first attack 
of the disturbing agent immediate alteration occurs in the circula- 
tion or nutrition of the part, the tubules being filled up and solidi- 
fied, or the attempt made, by deposit of adventitious matter, the 
disease being thus resisted and retarded ; conquering only when the 
attacking agent is stronger than the vital force which combats it. 

Such phenomena express to the observing mind the principles of 
the treatment of dental caries, i.e. to relieve the part from the agent 
of offense, and to strengthen the resistive ability. 

Passing from the first of these principles, which has been con- 
sidered on preceding pages with perhaps quite sufficient fullness, we 
proceed to the discussion of the second. 

A tooth attacked at a given point by irritating agencies will, 

step by step, break and give way before the irritant ; or, otherwise, 

will resist and antagonize. Resistance implies assistance, which 

assistance may be either of nature or of art, or of both. What- 

(274) 



LOCAL TREATMENT OF DENTAL CARIES. 275 

ever shall tend so to consolidate or protect the parietes of a cavity 
as to render the parts impervious and insusceptible to external agents, 
will save the tooth. Such result is aimed to be secured through 
the removal of dead and dying dentine from a cavity, and provoca- 
tion to tubular consolidation through the introduction of an agent 
exciting to the vascular system of the tooth ; the chloride of zinc 
being among the best of such agents, and most conveniently em- 
ployed in the preparation known as oxychloride. (See Filling Teeth.) 
Zinc so introduced into a tooth will not unfrequently be found fol- 
lowed by such inflammatory consolidation that a cavity from being 
soft and of loose structure is seen to become solid and dense to an 
extent that makes it entirely self-protecting; it has become glass-like 
in hardness : this occurs, however, only where the vital force is able 
to respond to the excitation. The practitioner, aware of this fact, 
directs a medication to the assistance of an asthenic system laboring 
under advancing dental caries, precisely as, under similar circum- 
stances, he endeavors to assist nature in caries of bone proper. 
In the one case as in the other, thus only may he expect to get 
a cure. Such principle of treatment is so in accordance with the 
exhibitions of nature's expression, that no medically educated ex- 
perience may doubt the indications. 

The cure of caries by filing finds its explanation precisely as ex- 
pressed in the employment of the zinc. The file cutting away the 
weak point, and exciting, through the exposure of the dentine, in- 
creased vascularity, structural consolidation results, and thus external 
or offending agents are shut out, precisely on the same principle as a 
ball may become encysted in a bone and remain for years innocuous. 

Gold or other ordinary agents employed in filling act to an 
extent in the same way: these, however, being commonly non- 
irritating or exciting, are not apt to be found associated with the 
same extent of change ; in all reasonably vital teeth, how- 
ever, are to be seen such attempts at resistance. A fill- 
ing of metal represents, and, to a degree, stands in place 
of, the tubular or structural consolidation. 

Fig. 61 represents a section of carious tooth from life, 
exhibiting structural consolidation. In this particular 
case, although the cavity — being in a lower molar tooth 
— was large enough to contain a pea, caries was held completely in 
abeyance, and had been so for years, the parietes of the cavity being 
as hard as flint. 

In the local treatment of dental caries, three indications exist : 




276 ORAL DISEASES AND SURGERY. 

1. Neutralization of the oral fluids and the induction of a state 
of general health in the mouth. 

2. Medical treatment of the tooth. 

3. Mechanical treatment of the cavity. 

1. The normal condition of the oral fluids is neutral. A healthy 
saliva, in which practically is included the secretion of the mucous 
glands, as well as that brought into the mouth by the ductus sali- 
varii, is an inodorous, tasteless, slightly viscid fluid, bland, unirri- 
tating, subject to changes as influenced by physiological impressions, 
affording at times an alkaline reaction, again being temporarily 
acid, sometimes sweet, and often, under the impressions of dry 
bodies, mucilaginous to a marked extent, owing this last character- 
istic to excess of mucus, a substance almost analogous to vegetable 
mucilage, having as a chief constituent an albuminoid compound, 
with the office of preserving the membranes moist and in a condi- 
tion fitted to the performance of their functions.* 

* Messrs. Griffith and Henfrey, the able editors of the " Micrographic Dic- 
tionary," state, when speaking of the oral cavity : " The mucous liquid of the 
mouth contains, in addition to detached epithelial cells, very transparent cor- 
puscles about 1-2000 to 1-1500" in diameter, consisting of a delicate cell-wall, a 
nucleus, with a number of minute moving molecules. We have figured these 
among the test objects. (Plate I., Fig. 5.) They are called mucous or sali- 
vary corpuscles. Kolliker regards them as a form of exudation corpuscles ; 
and this view is probably correct, for they may occur in the secretion of any 
mucous surface and have no special connection with the salivary glands ; we 
have found them in myriads in the urine." 

Dr. Joseph G-. Richardson, of this city, Lecturer on Pathological Anatomy 
in the University of Pennsylvania, claims, however, to be the first to demon- 
strate their true nature and origin, viz., that they are simply ''migrating" 
white blood-corpuscles, which have become distended by the endosmosis of a 
fluid less dense than the liquor sanguinis. He remarks, "Prom my experi- 
ments as detailed in the same article, page 253, and briefly described on page 
157 of this chapter, I conclude that ' tracing now the white blood-corpus- 
cle from its condition of irregular outline and amoebaform movement, as ob- 
served in serum and in heavy urine, when the circumambient fluid approaches 
the density of 1028, through its rounded form, with slightly more distinct 
nuclei, in the liquor puris and in urine of lower specific gravity, we find 
that immersed in a rarer liquid approximating to the mean density of the saliva 
(1005J, it has an accurately spherical outline, is more than twice the magni- 
tude, and contains a number of minute actively-moving molecules, thus 
exactly resembling in all sensible characters the true salivary corpuscles ; and 
it therefore seems reasonably certain that the blood, under the appointed 



LOCAL TREATMENT OF DENTAL CARIES. 277 

The analysis of the fluids bathing the teeth is to precede opera- 
tions upon these organs. As acidity or alkalinity is concerned, such 
analysis is most easily made — demanding but a few days — by fur- 
nishing the patient with two strips of test-paper, — litmus, as it is 
called ; paper colored with the dye of the plant Lichen roccella, — 



nervous influence, congesting the buccal mucous membrane and associated 
glands, moves slowly enough through their capillaries to allow some of its 
white globules to penetrate the walls of the vessels, as they do those of the 
frog's mesentery in Cohnheim's experiment (Vir chow's Archiv, Band xl., S. 
38etseq.), which, under the influence of the rarer saliva expanding them and 
setting free to move their contained molecules, constitute the bodies so long 
known to histologists as the corpuscles of the salivary fluid." (Vide Hand- 
book of Medical Microscopy, p. 165.) The demonstration by Dr. Kichardson 
is as follows: "Placing a drop of blood from the tip of my finger," says 
Dr. R., " upon a growing slide" (see Pennsylvania Hospital Reports, 1869), 
" I covered it with a thin glass and placed it upon the stage of the microscope. 
After finding a white blood-corpuscle showing well-marked granules, I 
raised the objective and arranged a fine filament of thread from the reservoir 
filled with fresh water to the upper edge of the cover, and a fragment of wet 
paper to the lower, according to the usual method for securing a constant 
current beneath the thin glass. On depressing the body of the instrument 
and bringing the corpuscle again into view, I found it still adhering to the 
surface of the cover, notwithstanding the torrent of red globules hurrying 
over the field ; and as these became paler and less distinct by reason of the 
diminished density of the serum, the white cell first gradually expanded and 
displayed its delicate wall with two rounded nuclei, then, after acquiring the 
magnitude of about T Too^ n °^ an i" ^? it exhibited the rapid and incessant 
movement of its contained molecules, and, finally, when its diameter reached 
about the x^V^th of an inch, it burst suddenly, discharging a portion of its 
contents, whose outbreak resembled that of a swarm of bees from a hive, and 
some particles of which, actively revolving as they went, swam off to the 
confines of the field. On repeating the observation and allowing some aniline 
solution to flow in with the water after the first few moments, the nuclei were 
strongly stained and beautifully distinct, although the movements of the 
molecules promptly ceased, — in this respect, as in all the others, showing a pre- 
cise identity with the reactions afforded by the pus and the salivary corpuscles, 
as above described. It should be noted that a certain variable proportion of 
the white cells of the blood thus treated exhibited no moving molecules, and 
apparently consisted solely of nucleus and cell-wall." 

Since the above was in type, this doctrine seems to have been corroborated 
by further experiments of Dr. Richardson, in which salivary globules were 
again reduced to the size of the white cells of the blood, and their amoeboid 
movements restored, under the influence of a three-quarter per cent, solution 
of common salt. (Vide paper on the Structure of the White Blood-Corpuscles, 
Transactions of American Medical Association, 1872.) 



278 ORAL DISEASES AND SURGERY. 

one piece being blue, as found in the shops ; the other made red by 
subjecting it to the action of a weak acid, or for this latter purpose 
turmeric paper may be used. Having these pieces of test-paper, the 
patient is to wet them, slip after slip, at varying periods of the 
twenty-four hours, particularly in the morning immediately upon 
rising and before taking anything into the mouth. If persistently 
the result is acid or alkaline, as evidenced by the blue slips being 
turned red if the first condition exists, or the red slips of litmus 
being changed to blue, or the yellow of the turmeric to brown, if 
the action is alkaline, then is primarily indicated the necessity for 
antagonizing agents as suggested in the prescriptions presented a 
few pages back. 

When sordes are found enveloping the teeth, or where the mucus 
is glairy, the condition manifested by such secretions is to find cor- 
rection before any reasonable hope is to be indulged of saving the 
denture or of making mechanical operations which may have in them 
any special import of good. (See Mucoid Saliva.) 

The restoration to a state of health of gums, turgid and congested 
from any cause, is to precede dental operations ; of such causes of 
ulitic troubles there are many. These will be found discussed in the 
chapter on Diseases of the Gums. In a word, attention to local or 
systemic indications is to precede, or have association with, as 
judgment may determine, the operative requirements of existing 
cavities of decay. 

2. The physical history of a tooth to be treated demands con- 
sideration. Teeth so vary in character as to suggest their division 
into four classes. 

I. Teeth of the Sanguine and Allied Temperaments with Similar 
Hereditary Association. — These teeth are white, shading into a cream 
tinge which deepens as it approaches the gum and as age advances: 
the organs are uniform in dimensions and arrangement, are dense, 
and have periostea of the most resisting character, — the associated 
alveolar process being condensed to a corticle-like extent ; their rela- 
tion with the jaw is so unyielding as not unfrequently to suggest 
union of the parts. These teeth, as justly remarked by Harris, indi- 
cate, "if not perfect health, at least a state which bordered very 
closely on it at the time of their dentinification, and the posses- 
sion of stomachs always willing to digest whatever the teeth are 
ready to masticate." 

II. Teeth having a Blue Shade. — These, without doubt, are much 
more common to females than to males. Constitutionally they indi- 



LOCAL TREATMENT OF DENTAL CARIES. 279 

cate the lymphatic temperament. They are commonly super-sensitive, 
having a softness yet tenacity of structure that expresses dispropor- 
tionate excess in animal matter ; observation seems to indorse the 
conviction that such teeth are associated more or less in a hereditary 
history with struma. Certain it is, that to preserve them the most 
constant watchfulness is necessary, both as a systemic and a local 
aspect are concerned. 

III. Chalky Teeth. — Teeth of this class are not unfrequently to 
be met with having so little mechanical resistance as to suggest 
their relation with plaster of Paris. As such teeth have in them- 
selves no resistive force, an only hope of prolonging their existence 
lies in the antagonizing of agents injurious to them. Thus arises a 
necessity of that care on the part of a person so afflicted, which is to 
keep him informed continuously of the state of the oral fluids, or if 
such care is not consistent with the character of the individual, 
then are antacid agents to be kept in constant use. 

IV. Pearly Teeth — Teeth frequently found allied with the Tuber- 
culous Predisposition. — Teeth of this class are commonly of great 
symmetry, being in harmony with the delicate stature of the indi- 
vidual, and akin with the organization which has produced them. The 
inherent force of such organs is much in proportion with that of the 
common body. A treatment which tends to preserve them is that 
which increases the physical integrity of the individual at large. I 
am not aware of any peculiar local tendency to disease in them. The 
fluids of such mouths are commonly neutral. 

Teeth of the first and fourth classes seldom have indications of 
any required direct preparatory treatment. Teeth of the third class 
may only have immediate adverse associations antagonized. Teeth 
of the second class, however, — and these constitute four-fifths of all 
diseased teeth, — are benefited by direct local medication to a degree 
that is oftentimes found to be their salvation. 

A soft moist denture indicates non-resistance on the part of the 
immediate vital force (residing in the organ) to the advancing dis- 
ease. There is here little or no antagonizing structural consolidation. 
Can this be remedied ? Without doubt, in perhaps the majority of 
cases it can ; such remedy residing in stimulation of the dental 
pulp, and in affording to it a power of response. To secure such 
response implies combination with the local of general stimulation. 
As the first is concerned, it has been implied that no agent sur- 
passes the aqueous solution of chloride of zinc as used combined 
with osteo-dentine. A soft, non-resisting tooth, in which such 



280 ORAL DISEASES AND SURGERY. 

a temporary plug has been used, will not unfrequently in the course 
of a few months be found so hard that an ordinary excavator shall 
scarcely be able to make an impression on the dentine ; indeed, in 
many cases, so thorough has been the calcification that no other 
treatment is found necessary : the caries has been cured, the dentine 
vitrified.* 

In the employment, however, of such stimulation, it is to be in- 
ferred that the nicest exercise of judgment is demanded. Quite as 
many teeth are destroyed by chloride of zinc fillings as are saved ; 
perhaps the preponderance is to the first side ; but this is the fault of 
a practice which overstimulates, provoking inflammation and sup- 
puration where gentle excitation to a hypernutrition is alone de- 
manded. A good rule to adopt is to feel one's way, recognizing 
always that the extent of local stimulation is to be commensurate 
with the ability of the pulp to respond ; the object aimed at being to 
re-excite the formative capacity of the pulp, thus to oppose advancing 
disease by securing a calciferous barrier. 

Secondary indications to be met preparatory to filling a carious 
tooth exist in a necessity for the destruction of any fungi that may 
be found in the cavity, the immediate antagonism of the carbonic or 
other acids, or any alkali temporarily present, and the saturation of 
the part with an antiseptic, — warm alcohol being about the best 
preparation that may be used for the last purpose. By saturation 
is meant that the dentine be bathed in this fluid after the preparation 
of the part and immediately before the introduction of the filling. 
A person undergoing the process of having teeth filled should freely 
use as a rinse alcohol and water, combined in the proportion of one 
part of the first to four of the second. Or, where the refrigerating 
influences of the spirit are found irritating to the cavity, it may be 
replaced by the permanganate of potassa, one grain to the ounce of 
water. Creasote is also justly lauded as an application to be made 
to the walls of a cavity just before the introduction of the filling. 
Or if the odor of this medicament is objectionable, it may be replaced 
with the glycerole of thymol, a preparation deemed to be possessed 
of all the virtues of the former article. 

* Vitrifaction, vitrified. The use of a term signifying glass — glass-like — 
would in such a case seem quite as permissible as its application to one of the 
humors of the eye, the condition being one of glass-like hardness and smooth- 
ness. Eburnification, or conversion into a substance resembling ivory, is 
another term used to express the same condition. 



CHAPTER XII. 

THE LOCAL TREATMENT OP DENTAL CARIES. 
FILLING TEETH, 

The treatment of carious teeth by filling presents itself under the 
twofold aspect of simple and complicated cases. The first considers 
cavities, without any organic expression on the part of the teeth 
affected. The second associates with the cavity vital complaint of 
various meaning. In other words, cavities which are as holes in 
pieces of ivory, the filling of which is a simple mechanical manipula- 
tion, to be done well or ill, according to the skill of the operator, 
and cavities which demand, previous to their filling, a treatment 
fitting them to endure the manipulation. 

Teeth are filled or stopped with various materials, the principal 
agents employed being gold, tin, amalgam, chloride of zinc, HilPs 
stopping, and gutta-percha. The basal requirements for a filling 
are — ability to withstand the mechanical influences of mastication ; 
resistance to chemical agents ; non-susceptibility to thermal changes ; 
qualities to admit of ease of introduction into a cavity, and consoli- 
dation ; harmony in color ; and the absence of properties injurious to 
the structure of the tooth itself, or to the system at large. 

Of such different materials, the very best, as a permanent filling, 
is gold ; after this, tin ; the other agents mentioned being employed 
chiefly for temporary purposes, — for example, in the practice of 
army or navy surgeons, or by physicians whose inclination or duties 
do not afford that practice necessary to the attainment of the required 
skill in the use of gold or tin. The plastic fillings, as they are called, 
are so simple and easy of introduction, that any trouble in their use is 
found to reside almost exclusively in the preparation of the cavity. 
(See Directions.) 

Gold, the best material to be employed, is used in two different 
forms, — gold-foil, or leaf gold, and sponge gold. 

Gold-foil comes to the operator in leaf form, done up in books, 
these leaves being of varying weight from two to two hundred 

(281) 



282 ORAL DISEASES AND SUBGERY. 

and forty grains, the number on the book designating the weight 
of the leaf. Of these different numbers, some operators prefer one, 
some another : it is perhaps a matter of choice rather than of real 
difference. Leaf foil differs also in the characteristics of adhesive- 
ness and non-adhesiveness. The first is, or may be made, so sticky 
that it can readily enough be stuck piece to piece, or welded. In 
this form it is now most commonly used, and maybe quite as easily 
attached and built upon the plane surface of a metal dollar as within 
the cavity of a tooth. To effect such a result, it is only necessary 
to keep the part and metal perfectly dry, and to use, preferably, 
instruments with serrated points or faces. A fault, however, fre- 
quently attaching to the adhesive gold, and which may result from 
lack of care or skill in working it, lies in a want of softness or 
ductility. 

Unadhesive foil, employed entirely by some operators, is worked 
with plain pointed instruments. It is used rolled up in the form of 
cylinders and mats ; as pellets ; twists ; or in ribbon strips : however 
worked, the principle of manipulation is the same, being that of 
wedging, one piece being supported by another. 

Sponge Gold. — This preparation, as implied in its name, comes 
in the form of a sponge or porous mass. It is most adhesive, and, 
as with the sticky foil, if kept perfectly dry during the process of 
manipulation, can be attached particle to particle, until a tooth, 
however broken and imperfect, can have its outlines perfectly 
restored. To use it, serrated pluggers are desirable, and the por- 
tion of the mass to be employed is to be separated or picked into 
small pieces by the employment of instruments rather than the 
moist fingers. A large piece, or a bulk of size sufficient to retain its 
place in a cavity, is to be first introduced and worked into a solid 
mass ; to this first piece particle after particle is to be attached until 
the cavity is filled. It is a preparation more tedious to work than 
the foil, and, for a perfect operation, would appear to demand much 
more skill, and infinitely more patience. In this, however, experi- 
ence seems to differ. 

Gold, as a preparation for filling teeth, while the most perfect 
article employed, is yet not without objections. It is, unhappily 
for this purpose, an admirable conductor of thermal changes, and 
when used in close proximity with the pulp of a tooth, not unfre- 
quently so irritates this organ as to result in its inflammation and 
death. Another objection lies in its color. 

Tin-Foil. — This is simply purified tin beaten into thin leaves. 



LOCAL TREATMENT OF DENTAL CARIES. 283 

It is worked precisely as gold-foil, and answers, to an extent, the 
same purpose. It is a softer metal, and less capable therefore of 
resisting the wear and tear of mastication. It is still more objec- 
tionable in color than gold, but possesses an advantage over it in 
being a less sensitive thermal medium. It is also comparatively 
inexpensive. Like the gold-foil, it is furnished in books. 

Oxychloride of Zinc, Osteoplastic, Tooth-Bone. — This is a prep- 
aration of oxide of zinc, silex, titanium, and borax, and is in the 
market in the form of a whitish, coarse powder. To use it, a small 
quantity of the material is mixed with a watery solution of the 
chloride of zinc, — which comes already prepared with the powder ; 
and in the form of a paste, thus produced, it is packed into the 
cavity. The most perfect dryness is necessary to any success in its 
use; and, if possible, the filling is to be protected from the fluids of 
the mouth for a period of several hours. This is to be accomplished, 
— first, by shielding the mass placed in the tooth while in the act 
of setting or hardening, through the careful employment of napkins 
and bibulous paper; and, second, by dissolving in chloroform a 
sufficient quantity of gutta-percha to make a thin paste. This, 
dropped from the point of an instrument over the filling, will per- 
fectly coat it, and remain adherent for a long while, — quite as long 
as is necessary. A solution of gum sandarac may be used for the 
same purpose. 

For use in very frail front teeth, this plastic preparation warmly 
commends itself. That it will be most apt to need frequent renewal 
is to be expected, but it is not unfrequently the case that by its use 
they may be saved for several years, while in such teeth it has an 
advantage certainly over gold in the matter of color. Osteoplastic 
has also its use as a filling for the pulp-chamber and as a non- 
conductor underlying plugs of metal. It is to be repeated that the 
highest essential to its integrity consists in keeping the material 
perfectly dry for as long a period as possible after its introduction 
into a tooth. That plugs of this material, when in relation with the 
necks of the teeth, are found to fail so repeatedly implies oftentimes 
a careless manipulation, which has allowed the filling to get moist 
before setting. 

A form of artificial dentine, known as Guillois' cement, attracting 
at present a good deal of attention, is a preparation which in 1856 
was introduced into the commercial market in the way of imitation 
coral, — sleeve-buttons, shirt-studs, and similar articles being made 
of it. 



284 ORAL DISEASES AND SURGERY. 

Dental societies and individuals discussing this agent disagree 
much as to its merits. It is generally conceded, however, that as 
a material to underlie gold it is not surpassed, while many of much 
experience insist on recommending it as the most reliable of all the 
plastic materials. It is manipulated precisely as the ordinary oxy- 
chloride of zinc. Dr. Du Bouchet, of Paris, who is very enthusiastic 
in his admiration of this cement, and who claims most satisfactory 
results, thus describes his manner of using it : 

"After the cavity is prepared by thorough excavation, though it 
is not necessary to shape as carefully as for gold fillings, place a 
little more of the powder upon a glass slab than is absolutely neces- 
sary, and near it a drop of the liquid ; then mix into as stiff a paste 
as possible by means of a small platina spatula, and with which 
place a small quantity in the cavity, pressing it into all parts with 
a small inverted cone-drill ; then fill the rest of the cavity with 
care, and allow a small surplus to bulge out, overlapping the edges 
of the cavity: then dry the filling with bibulous paper, varnish, 
and leave for another sitting, at which time trim with chisel, 
and polish somewhat, by means of tape, and then buckskin ; or, 
before the filling has entirely hardened, pass a burnisher over the 
surface lightly a number of times, taking care not to disturb the 
setting; this makes the surface quite dense, and leaves it in a 
better condition to resist the saliva; then varnish. By means 
of these precautions the material has a chance of becoming ex- 
tremely hard before the coat of varnish has worn away, leaving it 
exposed to the fluids of the mouth, — its only enemies in these 
cases." 

An objection certainly lying to the use of this cement is the length 
of time required in setting, thirty minutes scarcely sufficing for that 
condition which justifies the removal of the napkin. The ordinary 
American compounds set in from two to five minutes. 

Amalgam, — This is a preparation of silver and tin amalgamated 
with mercury. It is made by melting together varying proportions 
of the two first-named metals, say equal parts, or two parts of silver 
to three of the tin — different persons having different formulae — and, 
when thus united, is comminuted by the file, and put aside for use 
when needed. This material is furnished by the depots ready for 
use, being on sale in ounce and half-ounce packages. 

To make an amalgam, or paste filling, as it is frequently called, 
take a portion of these filings, enough to correspond with the size 



LOCAL TREATMENT OF DENTAL CARIES. 285 

of the cavity to be filled, place them in some convenient vessel, add 
a small quantity of mercury, rub the mass together for a few 
moments, and the solid grains will be found to have disappeared. 
Add now to the amalgam a few drops of deliquesced chloride of 
zinc, and again rub the whole together. As a result, the bottom of 
the vessel will be covered with a dirty, black, pasty mass, while the 
amalgam, robbed of its impurities, will present itself as a fluid ball 
of frost-white silver. The next step is to take this ball, and, envelop- 
ing it in buckskin, cotton cloth, or linen stuff, press out, with for- 
ceps, the excess of mercury ; the result is now a semi-solid mass, 
which is the preparation to be used in the cavity of the tooth. To 
introduce this material, it is only necessary to thoroughly dry the 
cavity with bibulous paper or other absorbing material — supposing 
the cavity to have been previously prepared — and with any con- 
venient instrument press the paste into place, finishing it to accord 
with the articulating tooth. A few hours, and it will be found to have 
become as hard as the tooth. It may now be dressed and polished, 
and the operation is thus completed. 

The employment of the chloride of zinc as a purifying agent is 
not at all a necessity in the preparation of the mass, and may be 
omitted if not conveniently at hand. This mode of cleansing amal- 
gam was introduced several years back by the author, and seems to 
have passed into quite common use. After washing away the black 
sediment, the mass is to be thoroughly dried with the bibulous or 
other moisture-absorbing paper; such drying is to be insisted on, as 
it conduces much to the tenacity of the mass, through an influence 
on the process of crystallization. 

None of the materials employed in the operation of filling teeth 
has elicited so much discussion, pro and con, as amalgam. Without 
doubt, it will turn more or less dark every tooth into which it is 
introduced, and on this single account is not to be used in the front 
teeth. Still again, it oxidizes, thus giving a black and repulsive 
appearance to the mouth in which it is placed. That it affects 
the general health, as affirmed by many of its opposers, is not per- 
haps to be accepted as true. I am not myself able to recall any 
decided case of such a result. That, however, used in conjunction 
with other metals, the influence is locally bad, can scarcely be 
denied, — although exceptional cases may exist. No material is in 
more common use than amalgam ; thousands of teeth are filled with 
it every day, and it is not to be denied that cases enough present 



286 ORAL DISEASES AND SURGERY. 

where such a filling seems the only one that can be used. It is 
claimed that if a tooth be properly prepared, and the material be 
carefully introduced, an amalgam filling will last quite as long as 
would one of gold. Such an assertion applies only, however, where 
the process of structural consolidation is excited by the presence 
of the plug, or where the dentine of a tooth is naturally very 
solid. 

The use of amalgam seems necessitated in many cases in which 
gold cannot be used and where tooth-bone or the gutta-percha 
preparations might not bear the demands of the act of mastication 
or the action of chemical antagonists. In the teeth of soldiers, 
where the convenience of the service, lack of manipulative skill on 
the part of the surgeon with gold or tin, or the habits of most of 
the patients, would render the use of gold scarcely permissible, 
amalgam would certainly seem to recommend itself. (See strictures 
of Mr. Bridgman on the electro-chemical relations of the amal- 
gams.) 

HilVs Stopping. — This is a preparation composed of gutta-percha, 
quicklime, and feldspar ; it is to be purchased at any of the dental 
depots at a very reasonable price, and, as a temporary filling, may 
be highly commended: such a plug will not unfrequently be found 
preserving a tooth for several months, or, it may be, years. To 
introduce it, it is only necessary to soften a piece of the size required 
by laying it upon a heated plate, and while in such plastic condition 
introduce it, by means of any convenient instrument, into the pre- 
pared cavity. Care is to be exercised that no shreds be allowed to 
override the orifice of the cavity, such excess being easily removed 
with an instrument which has been held for a single moment in the 
flame of a spirit-lamp, or otherwise it may be dissolved and washed 
away with a pellet of cotton which has been saturated with chloro- 
form. This agent, while nicely smoothing the filling, is thought, 
however, by many to render it porous and brittle. The only objec- 
tion that may be urged against this compound, if used in accord- 
ance with the indications of cases as referred to in the previous 
chapter, is its lack of durability. 

Gutta-Percha. — This agent is not unfrequently employed as a 
temporary filling with most satisfactory results. It is treated pre- 
cisely as the HilPs stopping, and, as is seen, resembles this stopping 
when incorporated with other materials. Where one desires for 
himself to make a compound gutta-percha, it may be done by mixing 



LOCAL TREATMENT OF DENTAL CARIES. 



287 



a powder composed of quicklime two parts, very finely pulverized 
quartz, and feldspar, each one part; the softened gutta-percha is 
worked with this powder until it will hold no more without be- 
coming brittle. White gutta-percha is in itself, however, a most 
admirable temporary filling ; it adheres tenaciously to the walls of 
a perfectly dry cavity, and where it has been inserted with proper 
care may be depended on to preserve a tooth for a long time. I 
have seen a tooth and plug as good after two years' service as on the 
day of the operation. A filling of gutta-percha will commend itself 
above all others in very many instances. I have certainly seen it 
preserve teeth where the cavities were situated on the buccal and 
proximal faces of the molars and bicuspidati, in cases where gold 
had failed, an explanation of which would seem to be found in the 
illustration as exhibited in Mr. Bridgman's experiments. 

A form of gutta-percha preferred by many is that employed for 
making test-plates. Some of this is found exceedingly tough and 
resistive, and will, without doubt, make a filling which may be 
trusted for a long time. 

From this review of the materials employed in filling teeth we 
may pass to instruments and apparatus required in the manipula- 
tions. 

Excavators. — An excavator is an instrument designed to excavate 
or clean out a cavity. Excavators, while variously modified, are 
founded on two elementary styles : one, hoe-like in shape, cutting 
as drawn toward the operator, the other represented by the relation 
of the edge of the ordinary hatchet to its shaft or handle. 



Fig. 62. — Hoe Excavators and Modifications. 

i n n n n n r 




288 ORAL DISEASES AND SURGERY. 

Hoe Excavatoes and Modifications. 




I I 




f&lfM 



Fig. 63. — Hatchet Excavatoes and Modifications. 

MM HI illl I' 1 "! 






Fig. 64. — Rose Deills and Speae Deills. 



I 



LOCAL TREATMENT OF DENTAL CARIES. 289 



Rose Drills and Spear Drills. 




Examination of the diagrams gives the general idea of these in- 
struments. Unless, however, made of the finest steel, and shaped 
and tempered with the nicest appreciation and care, it is impossible 
to execute with them the requirements demanded. Excavators fit 
for the hand of the operator should first be able to endure the test 
of an unturned edge when used to cut a cavity in a piece of ivory. 

Drills — Rose and Spear. — Associated for a common purpose with 
the excavator are the spear and rose drills ; these instruments, per- 
fectly exhibited by the diagram, are found happily adapted to the 
reaming out of cavities upon the grinding and other exposed sur- 
faces of the teeth. When properly tempered, they cut with great 
rapidity, and while clearing the cavity tend also to give convenient 
shape for the retention of the filling. They are used also for the 
purpose of securing what are called retaining points for plugs, a 
matter to have consideration in connection with particular cavities. 
Drills, like excavators, are made with handle and point in one piece, 
or are fitted to separate handles, which may be made of steel, ebony, 

19 



290 



ORAL DISEASES AND SURGERY. 



pearl, or more expensive material, to please the taste ; the single 
piece is, however, commonly preferred, as being the most con- 
venient form. To use this instrument it is only necessary to rotate 
it between the thumb and finger, or, where pressure is found desir- 
able, the palm of the hand may be spared by receiving the butt of 
the drill in a socketed ring or thimble. Drills are also used associ- 
ated with handles, which allow of application at any angle desired. 
Of such stocks there are quite a variety, the most simple of which 
is perhaps that known as Merry's. Fig. 65 exhibits this drill as 



Fig. 65 




Merry's drill, ivory handle. 



Bur thimble. 



ready for use. Fig. 66 represents the bur thimble : this consists of 
an open ring for the middle or the index finger, with a socket at- 
tached, in which rests the end of the handle of the drill. It not 
only saves the hand, but the instrument is rotated much more easily. 

Instruments more lately introduced, and growing rapidly in 
favor with operators, are Green's pneumatic engine, Morrison's 
burring apparatus, Black's and Bonwille's office lathe and finishing 
drill. These are all labor-saving machines, and would seem pos- 
sessed of that principle which must eventually bring them into 
general use. While these various appliances have a common pur- 
pose, — namely, the rotation of instruments used in preparing cavi- 
ties, cutting down and finishing fillings, removing tartar, polishing 
teeth, etc., — the first differs from the others in having its power 
supplied by a bellows which is conveniently worked by the foot, — 
Morrison's, Black's, and Bonwille's being worked by a treadle 
applied as in the ordinary lathe. 

It is claimed by the devisers of these various instruments that 
not only is there great economy of time through their use, afford- 



LOCAL TREATMENT OF DENTAL CARIES. 291 

ing to an operator the ability to fill many more teeth in a given 
period, but that in every respect greater comfort is secured to the 
patient, the instruments destroying, through rapidity of revolu- 
tion, — from fifteen hundred to four thousand in a minute, — the sen- 
sibility of dentine, relieving from the necessity of severe extension 
of the lips and prolonged sittings, and accomplishing besides a char- 
acter of work that could not otherwise be secured. An understanding 
of these instruments is had by referring to the Merry drill ; the new 
apparatus represents simply the application of power to this form of 
machine. The oral surgeon who may find himself closely restricted 
to the operations upon the teeth must certainly discover his conveni- 
ence and comfort consulted in employing in his practice the aid of such 
appliances. An objection offered against their use, but one which 
the manufacturers will, without doubt, shortly overcome, is deficiency 
in working with that trueness which enables the operator to possess 



Fig. 67. — Forms of Chisels used in Dentistry. 

A i A 






1 II // 


/ / ((ff 


1 1 


1 1 


(If If 

III 1 1 


1 1 \\ 


t m { 

II u 

1 1 1 


lii 

I 



292 



ORAL DISEASES AND SURGERY. 



Fig. 68. — Jack's Double-End Enamel Chisels. 



s: 



V 




3 4 



over his drill the desired, and, indeed, absolutely neces- 
sary, control. 

Instruments most frequently found demanded for such 
exposure of a cavity as shall allow manipulation with 
the excavators and drills, are chisels and files. All cavi- 
ties in proximal surfaces require the employment of these 
instruments. Both, as would be inferred, have a variety 
of modifications. But with whatever particular one an 
operator may find himself able most conveniently to meet 
the indications of his case, that is the one he is to employ. 
As experience has made felt the necessity for the modi- 
fications, so a very little practice will best show the 
operator which of the forms he may select to meet his 
purpose. 

Fig. 67 exhibits the style and form of chisels in or- 
dinary use. A modification on these chisels is known as 
Jack's double-end enamel cutters. Six instruments con- 
stitute a set, such a set being designed to furnish " all 
the forms needed for freely cutting the enamel in sep- 
arating teeth." Fig. 68 exhibits these chisels. 

Still another character of chisels are those designed 
for opening fissures, cutting retaining points, and also 



LOCAL TREATMENT OF DENTAL CARIES. 293 

Fig. 69. 





8 9 10 11 



for enamel cutting, wherever applicable. Fig. 69 exhibits what 
are known as Forbes's gouge and Jack's paraboloid chisels, — 
instruments in general favor with operators, and capable of ac- 
complishing their work most satisfactorily. 

Nos. 1, 2, 3, 7, 8, and 9 show the Forbes's gouge ; and Nos. 
4, 5, 6, 10, 11, and 12 illustrate Dr. Jack's paraboloid chisels. 



Files. — Fig. 70 represents a simple straight file; which is 
to be viewed as the base from which the varieties digress. A 
file of such form would at once be accepted as well adapted to 
separating two proximating surfaces, as, for example, the in- 
cisor teeth. 

Such plain files, while alike in general form, differ greatly in 
thickness of blade and depth of cut, some indeed being so deli- 
cate as rather to act the part of burnishers, following those of 
heavier cut. Plain files are employed in separating the ante- 
rior ten teeth, superior and inferior. 

A form of plain file preferred by many operators is that 
suited to a common carrier. Fig. 71 represents such a file and 
carrier. 

A form of separating file in common use, without doubt the 
most convenient, and the least expensive, is exhibited on a fol- 
lowing page. (Fig. 79.) These are to be procured in packages 
of assorted sizes. 

Separating files, so modified as to be adapted for convenient 
use with the back teeth, are also shown. (Fig. 85.) 



Having thus exhibited the instruments necessary for the exposure 
and preparation of a cavity, we pass to the study of the manipula- 



294 



ORAL DISEASES AND SURGERY. 



tions ; and first we consider the most simple of cavities, i.e. a hole 
more or less round, situated on the grinding face of a molar tooth. 
In Fig. 12 are exhibited a number of these simple cavities. Sulci, 
so presenting, vary in the extent of the underlying decay as influ- 
enced by the structure of the organs in which they are found. In 
teeth of dense material, for example, they will seldom be found larger 
within than at the orifice. On the contrary, where the dentine is 
loose and non-resisting, as found in classes two and three, a verv 



Fig. 70. 

1 



-Separating File. 



small orifice will not unfrequently be found to lead to most exten- 
sive disorganization. To prepare such cavities for filling, an operator 
may use either excavator or drill, as may be preferred : perhaps the 
most simple means is found in the drill: selecting a size suited to 

Fig. 71. 



i\\\w\\\\\w\mm\\wvw 




Fig. 72. 



the orifice, the operation consists simply in reaming out the hole, 
the single precaution being observed of having the common diameter 
of the cavity as large as the outlet ; to have it a trifle larger is 
better, as thus a filling is retained with greater security. 

In cases where, after breaking through the orifice, a large cavity 
is seen to exist, drill after drill of increasing sizes may be employed, 

thus making the circumference of the 
orifice correspond with the cavity 
being made within. Or in such cases 
as present a resisting enamel the 
orifice is to be most conveniently 
enlarged through the use of the 
chisel. Selecting one of suitable size, 
the operator, little by little, chips 
away the operculum until the circumference of the diseased dentine 
is exposed ; this accomplished, it remains only to refer to the drill 
or excavator. In using a rose drill, the precaution is to be taken of 
avoiding the evolvement of discomforting heat ensuing from rapidity 
of rotation, which is to be done by careful drilling, or otherwise the fre- 
quent dipping of the instrument in cold water. 




Simple cavities on grinding face 
of molars. 



LOCAL TREATMENT OF DENTAL CARIES. 295 



Fig. 7; 




Cavities on posterior face of incisors. 



Fig. 73 represents cavities frequently found on the posterior face 
of incisor teeth. Such cavities correspond closely in their mode of 
preparation with those just described. A peculiarity occasionally 
observed, however, exists in the tendency of a delicate line of 
disease to start from the bottom of the common cavity, making its 
way directly toward the pulp-chamber: where such line is found, it 
is neither necessary nor desirable to associate it with the first 
cavity otherwise than by a reaming correspondent with its own 
size : should it be found to increase 
greatly in sensibility as it approaches 
the pulp, my own experience has satis- 
fied me that it is much the best plan to 
allow a portion of the diseased dentine 
to remain ; harm will not be apt to 
ensue from its presence if it be disin- 
fected and put into a state of neutrality, such diseased neutralized 
dentine most frequently becoming encysted ; that is to say, when 
properly treated, — as has been referred to, — being surrounded by 
a wall of consolidated tubules, while protected of course externally by 
the overlying filling. Rose drills are commonly used, to the ex- 
clusion of other instruments, in the preparation of these cavities, 
although the occasional convenience of the excavator is not to be 
denied. Great care is to be exercised in these cases, as, indeed, 
in all others, to have the orifice of the cavity sharply defined in 
its circumference ; if it be strictly round, so much the better, as 
thus the material used in filling can be made the more easily to asso- 
ciate harmoniously with it : such union being an absolute essential 
to the integrity of any plug. 

Fig. 74. Fig. 75. Fig. 76. 





Cavities at neck — anterior 
face — of incisors. 



Cavities found in the midst 
of imperfect enamel. 



Cavities on buccal face of 
molars. 



Fig. 74 represents what may be described as the third class of 
cavities : they are very frequently met with in the position shown in 
the cut. A more common location, however, is on the buccal face 
of the molar teeth in a sulcus about midway of this face. 

When situated as seen in the drawing, part of the cavity being 
overlaid by the gum, it will be found most convenient to remove a 



296 ORAL DISEASES AND SURGERY. 

portion of the carious dentine by the use of the excavator, and, thus 
securing a cavity, stuff it firmly with a cotton filling, which is to be 
allowed to project to some little extent; this filling, as it absorbs 
moisture and swells, naturally throws the gum from off the cavity, 
thus allowing the completion of the excavation as described in the 
previous cases. 

Fig. 75 represents a condition of imperfect enamel, in which are 
frequently found a number of pits : if examination reveals the bot- 
tom of such pits to be enamel-covered, they need not be filled ; if, 
however, the sharp point of the instrument used for the exploration 
be found to stick or wedge, then they are to be reamed out with the 
spear or rose drill. Not to treat and fill such cavities would be to 
allow caries to destroy the teeth. Unless of themselves running 
into each other, these cavities are not to be associated. Situated on 
the buccal faces of the molars, such cavities are to be reamed out 
with the rose drill. A complication frequently found to exist is 

where, starting from such a 
G ' ''' point, or it may be in an abra- 

sion near the neck of the tooth, 
the disease extends laterally, 
scooping out, as it were, a 
cavity (Fig. 17) : here the ex- 
cavator is found most conve- 
nient, while the employment of the chisel to uncover the caries is 
most likely made necessary. In excavating cavities of this aspect, 
it is common to have a slight undercut immediately beneath the 
enamel ; such undercut being necessary for the support of the filling. 

From cavities situated as just described, we pass to the consid- 
eration of others so related as to demand for their exposure not only 
ingenuity, but also such clinical data as shall show what extent of 
chiseling, filing, or pressure is permissible, not alone as the endurance 
of the teeth is concerned, but as reference shall be had to appear- 
ance, and, where possible, to self-cleansing surfaces. 

The denture shown in Fig. 78 is a type of many often exhibiting 
themselves. Upon the left side are shown the teeth as involved by the 
caries when a patient presents himself. Upon the opposite side are 
represented the same cavities when made ready to receive the 
filling. The second and third molars of left side, however, are 
utilized to exhibit contour cavities. 

Proximal cavities are to be exposed by Y-shaped filing. This is 




Cavities on buccal face of molar: 



LOCAL TREATMENT OF DENTAL CARIES. 



297 



the common rule, yet having exceptions, as will hereafter be ex- 
plained. A central incisor tooth, decayed upon the surface con- 
cealed by its neighbor, the relation of the teeth being as exhibited 

Fig. 




Pig. 79. 



Carious denture. 

in the diagram, the operation of exposure is commenced by passing 
a delicate separating file between the two 
teeth, a shoulder, however, being left at the 
neck, which is to prevent the future falling 
together of the cut faces. Space for the play 
of the file being thus secured, the first in- 
strument is replaced by a second, this latter 
being curved in its blade, and having a single 
cutting surface, which is slightly convex. 

I With the convex file, it is plainly seen that 

v ) it is only necessary to incline the free face 
fill I I against the tooth not to be cut, that the 
mm jjj J inclined plane looking inward shall be made 
SB ji J to act upon the affected tooth. (See diagram.) 
jjjj H I When the decay is common to both teeth, 
IB fc H ^ e double filing is seen to make the V-cut 
jl I with the base backward. Looking at the 
central incisor on the right of the diagram, 
is of convex face.) the cavity (shown on the left incisor) is 

found placed on the inclined plane, all its 
parietes being exposed and easy to get at. This has been the result 




298 ORAL DISEASES AND SURGERY. 

of the filing. The tooth, while widely separated from its fellow 
behind, affording plenty of room for operating, shows in front but the 
space made by the passage of the delicate separating file. This mode 
of separating applies to the six anterior teeth. 

After making the primary cut with the separating file between 
the teeth from the front, it is the habit with many operators to rely 
for the back separation principally on the chisel. If handled deli- 
cately, there is perhaps little doubt that this instrument is found 
least disagreeable to the patient, and, when used sharp and of proper 
curvature, it will most satisfactorily accomplish the work: the file, 
however, is commonly employed to finish the separation. 

A proximal cavity, without complications, thus exposed (see cen- 
tral, lateral, and cuspid teeth in diagram), nothing remains but to 
treat it as the simple cavities before described, — that is, cut away the 
carious dentine, and form the cavity of a shape to retain the filling. 
Such excavating is generally done with the hoe and hatchet exca- 
vators, the head of the patient being thrown backwards. The rose 
and spear drills, however, at times are here found very convenient of 
use, particularly where, the cavity being of saucer-shape, what are 
called retaining points are required. 

Complications. — The cavities just described are those of such 

limited size as to have made no alteration in the front or back faces 

of the teeth. From the consideration of 
Fig. 80. , , , . , . 

such we pass to a class as represented in 

Fig. 80, where, as is seen, the labial face 

is markedly affected. 

In examining these teeth, let the student 

draw a transverse line midway between the 

cavities and the gum. From this first line 
let him drop vertically others which shall just include the carious 
breaks on the faces of the teeth. Where the cavities are no more 
extensive than exhibited in the diagram, he will find that the file 
removing all between his lines will yield no deformity,, but afford, 
on the contrary, a space possessed of healthy look and not unbe- 
coming singularity. As a next step, let the convex-faced file be 
used, cutting wider the space posteriorly so as to allow the cavity 
to be seen only from that surface. He has thus his cavities in the 
same position and relation as existing in the cases above described. 
A second complication on such order of cavities is where the 
teeth affected are so related to each other and to the arch, and 
the cavities of so extensive a character, as to make any alteration in 





LOCAL TBEATMENT OF DENTAL CARIES. 299 

the outlook impossible. Cases of this kind are found where caries 
has extended its ravages over half the anterior face of the tooth, or 
where a tooth has such position in the arch that what should be the 
proximal surface is found looking almost directly forward, the tooth 
being twisted, as it were. Conditions of such expression are com- 
monly treated by excavating in any manner found most convenient; 
the original contour of the tooth being restored by the filling; other- 
wise such teeth may be filed in front until resisting parietes to the 
cavities are found, and then treated precisely as in the case of the 
posterior Y. Teeth having the base of the V looking forward are 
of course objectionable, but many so treated — the fillings being very 
solid and highly finished — are far from unsightly. 

Another class of complications exist in teeth related as in Fig. 81. 
Taking the central incisors as the first 
demonstration ; the tooth on the right Fig. 81. 

side of the diagram is seen to over- 
ride its fellow and to impinge alone 
near the cutting edge. In cases of 
this kind it is scarcely probable that 
either file or chisel will be found admis- 
sible, as it is plainly seen that no expedient will apply to prevent the 
cut surfaces falling again together. In exposing the cavities in 
these cases, — if found, as is usual, on the covered surface, — the 
means employed is that of pressure, either a wedge of some soft wood 
or a section of tough rubber tubing being employed. Of the tw T o 
means, the immediate wedging by the wood is found to afford the least 
pain, a wedge of the proper size being driven delicately between the 
teeth until sufficient room to work at the cavity has been secured. 
Where the india-rubber is used, it is common to exert the pressure 
gradually, pieces of increasing size being introduced until the desired 
separation is obtained. Objection to such means of separating teeth 
lies in the soreness provoked, the subsequent operation of filling being 
at times rendered so painful as to be nearly if not quite unbearable. In 
using the wedge of wood, the separating, excavating, and filling are 
to be done at the same sitting. To introduce such a wedge, it is found 
most convenient to cut it on the end of a stick of some length, nick- 
ing deeply at the base of the wedge. It is thus easily thrust by the 
hand between the teeth, or allows of the convenient application of 
the required force by the mallet. When in place, the wedge is cut 
off at the nick. 

Referring again to the diagram, Fig. 81, another modification is 



300 ORAL DISEASES AND SURGERY. 

found in the relation of the lateral incisor of the right side to the 
central. As in the case of the central with its fellow, it is seen to 
override, but it differs from this first in possessing an impinging 
surface, continuing from the cutting edge to the neck. Teeth so 
related are to be separated, first, by the wedge introduced at the 
neck ; and, second, may have the space thus secured increased by 
the file, the cutting, however, to be so directed as to leave at the 
neck an unfiled portion which shall prevent the parts falling again 
together, after the removal of the wedge. To excavate and fill a 
cavity in such a situation would seem to be a very difficult matter, 
and, indeed, will be found so, unless the operator forces for himself 
space, and which in all instances is to be effected, wedges of wood 
or india-rubber and the file being used as found necessary. It is to 
be accepted as a rule that the file may be used where after-changes 
are not to bring the cut surfaces in contact. 

Still another modification is exhibited in Fig. 82. Here the gums 
are found somewhat receded, the necks of the teeth being exposed. 
In the proximal surface of each tooth near 
the gums is a cavity of decay. To get at 
such cavities, the space made by nature in 
the V-spaces seen in the diagram maybe all- 
sufficient. If this should not be the case, 
then the wedge may be employed, being 
driven midway between the cavity of decay 
and the cutting edge. Such cavities being excavated and filled, the 
teeth are allowed to fall together. It must be seen that the mis- 
fortune of fillings so placed would lie in the absence of self-cleansing 
properties, compelling thus continual care for their preservation. 
To obviate such an objection, the use of the chisel has been advo- 
cated, scooping out a Y-space which is to extend from the neck to 
the cutting edge, treating such teeth, indeed, precisely as described 
with the uncomplicated cases, — a plan undoubtedly to be preferred 

where no lateral pressure exists to force 
Fig. 83. the cut surfaces together. 

In Fig. 83, representing the six inferior 
anterior teeth, the same condition is ex- 
hibited as shown in Fig. 82. The plan of 
treatment would, of course, be the same. 

Other modifications connected with the 
anterior teeth will not unfrequently be en- 
countered, but with the general ideas here given the ingenious operator 





LOCAL TREATMENT OF DENTAL C ABIES. 



301 



will find in his own skill, after a little experience, all the directions 
required. 

In deciding on a mode of separating teeth, the practitioner will 
find constant demand for the exercise of judgment. It may be laid 
down, however, as a rule that never more than two teeth should be 
undergoing the process in the same mouth at the same time. When 
the rubber is used, it is also to be accepted as a rule that plenty of 
time should be allowed for the operation, — from two to five days 
being about the time required ; that when soreness arises no increase 
in the thickness of the rubber is to be made until it has subsided. 
As a rule, young teeth endure displacement better than old ones ; 
indeed, it seems to be a conclusion of many, that separation of the 
teeth in persons over forty years of age may be made with safety 
alone by the file. 

In filling proximal cavities, occasion is often felt for the use of a 
very temporary matrix, — a form of instrument lath-shaped in blade, 




which may be passed between the teeth, making a wall of support 
for the gold until convenience allows of its condensation. The flat 
blade No. 5 from the right, Fig. 84, represents such an instru- 
ment. It is a blade which will be felt to contribute very much to 
facility in filling such cavities. To use it, it is simply necessary to 
rest it flatwise against the neck-wall of the cavity, creating thus a 
fully-bounded hole into which the gold is worked. (See Matrices.) 
Modifications of excavators are also exhibited in Fig. 84, which 
will be found most valuable in excavating ; indeed, than the forms 
1, 2, 3, 5, and 6, left side of diagram, none better may be found. 



302 ORAL DISEASES AND SURGERY. 

They cannot be too highly commended, being recognized to apply to 
almost every form and position of cavity. 

Passing now to the bicuspid teeth, the diagram Fig. 78 ex- 
hibits approximal decay involving both teeth of the left side. Teeth 
presenting cavities to the grinding face, as here seen, will invariably 
be found scooped out, and overhung by unsupported enamel. To 
fully uncover such cavities, no instrument is better than the chisel, — 
the operator simply cutting away the operculum, directing, where 
possible, the greatest breadth of the cut inward ; such manner of 
cutting is expressed upon the opposite side of the diagram, where, 
as is seen, the cavities are fully exposed upon the sides of inclined 
planes, while the anterior faces of the teeth are not at all disturbed, 
the cavities being put into a position and aspect in which they may 
be esteemed as simple and without complication. 

Complications. — A first complication may be described as a 
proximal cavity associated with a second occupying the sulcus 
found on the grinding face of these teeth. Here a plan pursued by 
many consists in exposing the first cavity as just directed, and, this 
accomplished, preparing the second precisely as in any simple 
crown cavity. If both are found entirely separate, perfectly healthy 
dentine lying between them, they may be treated as distinct cavi- 
ties ; if, on the contrary, there is found to be the slightest associa- 
tion, they are joined together by cutting out the septum which re- 
lates them. 

A second complication is found in the existence of that extent of 
decay which has so weakened the front or back wall of the tooth as 
to make the removal of such wall necessary. Such a condition is 
unfortunate, as it renders the operation of filling more difficult, 
except, indeed, to the experienced, who are able to adopt the plan 
of making what is called a contour-filling, — that is, building up with 
metal the part lost. To prepare such a tooth for filling, the operator 
finds himself compelled to cut wherever the disease may lead him. 
This he does, using the chisel, — chipping away, little by little, the 
weak parts ; desisting only when the evidences of disease are passed. 
Commonly, teeth so decayed are found with the pulps exposed ; if 
this should not be the case in any particular instance, the question 
of how the required filling is to be retained becomes of all con- 
sideration in the cutting of the cavity, the answer mostly existing 
in the formation of retaining points. These are points or slots 
cut out of the dentine, allowing places of anchorage; fillings in 
such teeth being made — when gold is used — of that form known as 



LOCAL TREATMENT OF DENTAL CARIES. 



303 



the adhesive ; it being remembered that it was remarked of gold 
thus prepared that it could, with all facility, be built upon the sur- 
face of a metal dollar. 

Still another complication met with occasionally consists in cavities 
meeting in the middle from either proximal surface. Such cavi- 
ties are treated by cutting away with the chisel all the overlying 
grinding surface, thus making a common cavity, which occupies 
perhaps the whole body of the tooth. Thus exposed, this common 
cavity is excavated and cleansed precisely as though it were, what 
indeed it has become, a deep crown cavity. (See Matrices.) Such 
a cavity necessitates contouring. 

The most common form of decay found in the bicuspid teeth, 
excepting the proximal, is that running in the sulcus between the 
two cusps. Where this is simple, it is prepared for filling by ream- 
ing it out at either extremity with a delicate rose drill, and con- 
necting the two drill-holes by the employment of the excavator or 
chisel. 

A modification in this single groove is frequently seen in a middle 
point of division entirely healthy. If such septum is of any size, it 
maybe allowed to remain, and each cavity be reamed out separately. 




CB i™^^ 



*— — — 




Form of Files used in separating the Molar Teeth. 



When, however, the slightest doubt exists as to its integrity, it is 
much the safer plan to remove it, thus cutting the two cavities 
into one. 

We refer now again to the diagram, Fig. 78, and observe the 
relation of the proximal faces of the first and second molars as seen 
on the left side. These teeth, while presenting at the surface a 
healthy aspect, are yet found to have cavities midway of this face, and 
which, as thus situated, have only been discovered by the insinuated 



304 ORAL DISEASES AND SURGERY. 

point of a delicate excavator, or, what is more likely, the passage of 
a silk thread. Referring now to the opposite side, these cavities 
are found exposed. This is accomplished either by the chisel, or 
otherwise by files purposely prepared to make such a cut so far back 
in the mouth without interfering with the lips. Fig. 85 represents 
such files. The cavities, before unseen, are now exhibited upon the 
sides of the inclined planes, and fillings placed in them are recognized 
to have surfaces that must be self-cleansing. 

Passing to the grinding surface of these same teeth, cavities of 
decay are seen running out over the lateral walls. The excavation 
of these consists simply in following the sulci wherever they may 
lead, bearing in mind the fact that the excavation is to be of such 
character as provides for the retention of the filling ; that is, that at 
all aspects it is to have a wall slightly concave. Sometimes, when 
much depth has been attained by that portion of the decay in the 
crown, and perhaps as well that upon the side, — the connecting 
sulcus being of slight signification, — it is good practice to scoop out 
this intervening portion, without regard to the shape of its walls, 
and carry the adhesive gold, arch-like, into and over it from one 
plug to the other. 

Passing now to the proximal faces of the second and third molars, 
left side, attempt has been made by the artist to represent cavities 
in these teeth prepared for contour-fillings, — a plan of preparing all 
proximal cavities of any extent in the bicuspid ati and molars grow- 
ing rapidly into general favor, and certainly productive of the 
ability to make beautiful operations. First, it is seen that a sepa- 
rating file, slightly Y-shaped, has been passed between the teeth. 
Next, the cavities have been excavated, being cut directly down 
from the crown surface, and have been so shaped that in putting in 
the metal the operator works directly from this crown surface. 
These teeth are so excavated that when filled it is proposed to re- 
store fully the portion lost. 

The preparation of the teeth — molars or others — for contour-fill- 
ings must find direction in experience. It is to be recognized that 
the idea and intention are to repeat in metal what has decayed 
or been cut away. In proportion as the part removed has been 
extensive, so must it be recognized that proportionate difficulty will 
exist in securing fixedness for the filling. Contour-fillings, save in 
exceptional cases, should possess inclined surfaces. A filling which 
represents the surface of an inclined plane has been amply demon- 
strated by experience to be the better kind. 



LOCAL TREATMENT OF DENTAL CARIES. 305 

In excavating a cavity of any class, certain rules are to be 
observed and practiced : 

1. A cavity must have such exposure as shall afford room to 
introduce the filling properly. 

2. Walls are to be made as perpendicular as the case will admit of, 
and the margin of a cavity is to be at right angles with the sur- 
rounding surface. 

3. The orifice of a cavity is to be without fissures or irregularities 
wherever these may be avoided; must have a firm decided margin, 
and must be supported solidly by the underlying dentine. Rough- 
ness or brittleness in the edges of a cavity is most objectionable. 

4. In excavating a tooth, regard is to be had to the proximity of 
the pulp. A pulp is not unnecessarily or carelessly to be exposed, 
nor to be too closely approached ; for if the first, the case is immedi- 
ately changed from simple to complicated ; if the latter, the organ 
might eventually become chronically inflamed, and die, as a result 
of the thermal irritation arising from the presence of the filling. 
Neither is it permissible to file or chisel a tooth too freely, except 
where regard is had to the density of the organ. A tooth of very 
loose texture will not unfrequently have an inflammation of the 
dentine and pulp provoked by the removal of even a slight portion 
of its enamel, while, on the contrary, a tooth of very dense structure 
may commonly be cut with considerable impunity. 

5. In cavities having radii running from a common centre, which 
radii may not with propriety, on account of their extent, be included 
in a single round hole, care is to be observed that each extremity be 
rounded, never being allowed to retain its natural sharpness or 
fissure-like aspect. Crown fillings fail more frequently from the 
non-observance of this rule than from perhaps any other cause. 

In the process of excavating the teeth, the practitioner will re- 
quire, besides the instruments mentioned, a syringe for washing 
away the debris, and a mouth-mirror, to be used either for casting 
additional rays of light, or showing him more conveniently the cavity 
at which he may be working. Of the two mirrors exhibited, the 
form represented in Fig. 86 is the most desirable. Syringes are of 
various construction. Fig. 88 represents one made with a hand bulb 
of rubber. It is to be commended for a simplicity of construction 
which does not allow it easily to get out of order. 

20 



306 



ORAL DISEASES AND SURGERY 
Fig. 86. FlG - 87 - 



111 




Fig. 88. 




Fig. 89. 




CHAPTER XIII. 

LOCAL TREATMENT OF DENTAL CARIES. 

INTRODUCTION OF THE FILLING. 

The instruments required for introducing a tilling of gold will 
vary necessarily somewhat with the position of the cavity to be 
filled, and the character of the metal used, — whether adhesive or 
non-adhesive. 

A filling of non-adhesive gold is made on the principle of wedging. 

A filling of adhesive gold is made on the principle of interdigi- 
tation, or welding of the particles. 

To use the first form of gold, wedge points are employed. Such 
points, as for sale in the depots, are found of every variety of curve. 
A skillful hand, however, is best served in the forms represented in 



Fig. 90. 



Fig. 91. 





Plain-pointed pluggers. 



Serrated points. 



the diagram, Fig. 90, and in a single modification where the wedge 
is at right angles with the shaft. A wedge plugger may be slightly 
rough on its surface. 

To employ the adhesive gold, instruments with points more or 
less serrated are to be preferred. These serrations require to be kept 
very smooth on their planes, otherwise the metal is pulled away 
quite as rapidly as it is attached. Fig. 91 exhibits points of serra- 
tion magnified. 

The handle of a plugging instrument is to be round or octagonal, 
and so roughened that the hand shall hold it firmly, while the blade 

( 307 ) 



308 ORAL DISEASES AXD SURGERY. 

is to be of a temper which allows of the employment of the neces- 
sary force without danger either of breaking or bending. These 
instruments have of late been brought to such perfection by the 
makers that the operator need not hesitate to receive them as sup- 
plied. The temper, at the point, is to be of straw color, and from 
this, up to where substance gives strength, it is to be purple. 

As dryness is essential to the integrity of a plug, we digress at 
this point to review the means equivalent to such end. 

Napkins. — Answering in all ordinary cases we have the napkin. 
A dental napkin is an oblong square of linen, varying in size to suit 
the idea of the operator; dimensions which will be found conve- 
nient are: length, twelve inches; breadth, three. In applying this 
napkin to the upper denture, it is folded upon itself in part obliquely, 
until one end is brought to a point. Beginning with this point, the 
linen is laid delicately and smoothly between the gums and cheek, 
being carried backward or forward according as the initial end may 
have been placed, until turning into the mouth at a convenient dis- 
tance from the tooth to be operated upon, it is made thus to envelop 
the organ, being supported on either side of the arch by the fingers 
of the left hand. 

Applied to the lower denture, the napkin is first folded upon itself 
into a ribbon-shape of an inch in width ; second, the initial extremity 
is back-folded until a pad is made which shall correspond in length 
to its width, that is, being an inch each way. This pad is to be 
laid upon the floor of the mouth directly back of the incisor teeth, 
thus covering the orifices of the ducts of both the submaxillary and 
the sublingual glands : from this point it is carried around the arch 
into the vestibule as required. 

To hold the floor pad firmly in place, as is demanded, various 
plans are adopted. The most common one is, where the tooth to 
be filled is upon the right side of the jaw, for the operator himself 
to fix it by the thumb of the left hand while the index-finger is 
extended over the part occupying the vestibule. "Where the tooth 
to be shielded is upon the left side, the index-finger of the right hand 
of the patient is employed, the three remaining fingers being doubled 
out of the way beneath the chin. 

As the encroachment of the saliva constitutes about the most trou- 
blesome offense in dental operations, ingenuity has been exercised 
to its utmost for its control. Fig. 92 represents a tongue-holder 
devised by Dr. J. Foster Flagg. 






LOCAL TBEATMENT OF DENTAL CARIES. 309 
Fig. 92. 




"It will be found that the use of this instrument will insure addi- 
tional facility to the operator, and maintain the tongue in position 
with perfect comfort to the patient, producing no fatigue, no un- 
pleasant sensations, and even removing all desire to resist constraint. 
After introducing a fold of napkin, or a small piece of muslin, 
under the tongue, and then covering that organ by back-folding the 
napkin, or placing another small piece of muslin upon it, the holder 
should be put ih position nearest to the side where it is proposed to 
operate, and the patient be requested to retain it thus by means of 
the right hand if the cavity be on the left side, and the left hand if 
the cavity be on the right side, the elbow resting upon the arm of 
the operating-chair." 

Another instrument, a modification on an ingenious invention of 
Dr. Hawes, is that which bears the name of Morrison's compressor. 
(See Fig. 93.) The diagram fully illustrates its working. The 




Morrison's compressor. 



napkin, being put into place beneath the tongue, is held by the bars 
of the curve, the cup receiving the chin, the ratchet-work approxi- 
mating and holding the two parts in the required relation. A later 



310 



ORAL DISEASES AND SURGERY. 



instrument of this same character is one designed by P. T. Smith, 
p IG 94 D.D.S., the variation consisting in 

the sliding of the bar which supports 
the compress, and in an ability to 
change the position of the chin-rest. 
f A still later, is a porcelain tongue 
thimble, which highly commends 
itself. 

The annexed cut represents 
" a saliva-pump and tongue-holder 
combined, the invention of Dr. 
Dibble. The object of this instru- 
ment is to facilitate the operation 
of filling teeth of the lower jaw 
by keeping the mouth free from 
saliva, and as a means of holding 
the tongue away from the teeth ; 
also a means of supporting the 
upper jaw, and so assisting the 
muscles which keep the mouth 
open, the application of which will 
be readily understood from the illus- 
tration. The instrument is com- 
posed of coin silver heavily plated 
with gold, and hard rubber. A 
designates the plate which keeps 
the tongue away from the teeth ; 
B, the arm which supports the 
jaw; C, the silver tube and base 
which fit over the jaw ; D, the 
opening where the saliva enters the 
tube ; E, the chamber that receives 
the saliva. A vacuum is made in 
the saliva chamber by the pressure 
of the bulb I, thereby causing the 
saliva to flow into the opening D ; 
H, the opening where the saliva is 
discharged ; Gr, the exhaust-valve. 
There are two mouth-pieces, one 
for the right side and one for the 
left side of the mouth. 

" The instrument is readilv 




LOCAL TREATMENT OF DENTAL CARIES. 311 



cleaned externally by means of a brush, soap, and water; internally, 
by drawing soap and water through it. It must not be laid down on 
its side after using until emptied of saliva. The entire length of the 
instrument is fifteen inches." 

An instrument most happily serving as an adjunct to the man- 
aging of a napkin, holding in place pellets of spunk, bibulous paper, 
etc., is an extension-finger devised by Dr. J. II. McQuillen. This 
consists of a silver shield (see Fig. 95) (to be worn upon the index- 
finger) with a socket on the under surface, in which a steel finger B 
fits. A number of these fingers or bits bent at different angles 

Fig. 96. 
Fig. 95. 



McQnillen's extension-finger. 





Taft's thimble. 



accompany the shield, being adapted to meet the various require- 
ments. This instrument is also found of the greatest assistance in 
fixing mats of gold in position during the process of filling, doing 
away, in many instances, with the necessity for retaining points. 

A second form of instrument having a similar signification with 
that just described, known as Taft's thimble and extension, is repre- 
sented in Fig. 96. This thimble is to be used upon the index or 
middle finger of the left hand. It is also employed to aid in holding 
the napkin, paper, spunk, or whatever may be used to prevent the 
encroachment of saliva. The point of this instrument, like the first, 
can extend into the mouth where the finger, either on account of its 
size, or for want of length, cannot go. It may also be used to hold 
down a piece of gold until it is made fast in the proper position. It 
will likewise be found a convenience with which to reach over and 
draw the napkin up firmly against the lingual sides of the teeth. 

A form of compressor for the Stenonian duet, the invention of 
Dr. Rich, and figured on the following page, is thus described: 

" This forceps and spring professes to accomplish the closure of 
the duct more perfectly than any other appliance. The spring, with 
a pad of bibulous paper, or napkin, prevents all flow of saliva, 
while the tip is free to yield to every motion ; whereas with a wad of 
napkin in the cheek, the lip is tight, and very little motion frees 
the duct, allowing the saliva to flow. 



312 



ORAL DISEASES AND SURGERY. 



In use, the recurved ends of the forceps fit in the recess of the 

spring, which closure 
of the handles will ex- 
pand. Then, having 
placed the pad in posi- 
tion, — exactly opposite 
the second upper mo- 
lar, — release the grasp 
on the handles, the 
spring will close and 
forceps be detached at 
once. An outer pad 
may be slipped under 
the spring afterwards, 
if desirable.' 1 

An operative plan 
of controlling the pa- 
rotid secretions has 
been suggested, and 
perhaps to some ex- 
tent practiced, consist- 
ing in placing a tempo- 
rary ligature about the 
ducts. This is certainly 
to be opposed as an 
unsurgical proceeding, 
and one which might 
most readily eventuate 
in stricture. 

Of all the various 
appliances, however, 
aside from the napkin, 
designed for the con- 
trol of the salivary se- 
cretion, not one has 
seemed to meet with 
so universal an ap- 
if proval as what is 
known as . the coffer- 
dam of Barnum. This 
consists in a simple sheet of thin rubber, prepared for the purpose, 







LOCAL TREATMENT OF DENTAL CARIES. 313 

into which one or more minute holes are to be punched for the 
passage of certain teeth associated with the proposed operation. 
When properly applied, even a lower tooth may be protected from 
the saliva for a period of four or five hours, should such time be a 
requirement. 

In applying this dam, the operator starts with the principle that 
a delicate round hole is to be made in a sheet of rubber; this is to 
be stretched by passing the diseased tooth through it. The rubber 
thus tightly grasping the tooth is forced beyond the place of decay, 
putting the cavity in a water-tight dam. 

Applying this dam of Dr. Barnum to an isolated tooth, an oper- 
ator would be led to conclude that nothing was left to be desired ; 
passing, however, to one of complicated relation, he would err as far 
on the other side in inferring it to be without value. That the reader 
may be possessed of a proper appreciation of the capabilities of the 
appliance, attention is directed to the communication of a gentleman 
who seems to have had all necessary experience in this direction, 
J. F. P. Hodson, D.D.S., being an essay offered by him for the 
consideration of the First District Dental Society of New York. It 
will of course be found that others have expedients to meet the 
same indications varying markedly in character. These expedients 
come to suggest themselves to every person of reasonable ingenuity 
as experience widens, but, as a study, the suggestions in this paper 
cannot fail to afford many useful hints in the direction of the use 
of this dam. As a study simply, it is quoted. 

" Experience," says this gentleman, " only can enable one to judge 
as to just which cases to apply this dam. As an operator becomes 
more and more skillful through practice in manipulation with it, he 
will find the cases to which he cannot apply it becoming fewer, and 
in the course of time discovers that whether to apply the dam or not 
to any case — perhaps one in fifty excepted — becomes merely a ques- 
tion of expediency. 

u I seldom," he continues, " use the dam for simple cavities in the 
grinding surface of superior molars, but lay a narrowly-folded 
napkin or bibulous paper along the gum outside instead. I do use 
it, on the other hand, in almost every case, for the lower teeth, and 
nearly always for approximal cavities, wherever situated. 

" Two or three, or, in extraordinary cases, more teeth, should be 
embraced by the rubber, unless the tooth operated upon is standing 
isolated from the rest. The holes should be as round as possible — 
as a sharp angle in them is a tear suggested — and very small, 



314 ORAL DISEASES AND SURGERY. 

though varying with the resiliency of the rubber, — say the size of 
an ordinary pin's head for a bicuspis, and in this proportion for the 
other teeth. The distance which the holes should be apart must 
be a matter of judgment for each case. Where the teeth are near 
together, they may be within an eighth or three-sixteenths of an 
inch of each other. Where there is a wedged space and approximal 
cavity, it is a nicer matter to determine, as you must have sufficient 
rubber between the holes to allow for both teeth being embraced so 
snugly as not to admit of leakage, while an excess of rubber would 
puff up between the teeth, and hide that essentially important point, 
the cervical edge of the cavity. After the holes are cut, carry 
the rubber down between the teeth with waxed floss silk, being 
careful to place the silk as near as possible to the edge of the hole, 
otherwise the rubber will be torn. It is more convenient to com- 
mence with the tooth nearest the front of those which are to be 
embraced, and apply to each one back of it successively, till all are 
encircled. The edge which now stands up against each tooth must 
be turned under, to prevent leakage. This may be accomplished by 
carrying the floss tightly against the approximal surface of each 
tooth, and down upon its neck; then, with a small burnisher, com- 
plete the circuit by turning the edge upon the buccal and lingual 
surfaces. This is all done when the rubber is applied, and does not, 
in practice, consume one-quarter of the time'that it takes to write 
it. At the first and last spaces leave the floss, to prevent the slip- 
ping off of the rubber. 

"Incases of partially-developed teeth, or those whose crowns are of 
too conical a form to retain the rubber unassisted, special appliances 
will be required. Some operators suggest, for the lower teeth, tying 
a piece of twine or floss around the tooth over the rubber, attaching 
a small weight to the ends, and allowing' it to hang down out of the 
mouth. This, to my mind, has many objections, chief and conclu- 
sive among which is the fact that when the tooth is sufficiently 
developed to apply this string-holder, I can entirely dispense with 
its use, and depend on leaving the floss between the tooth and 
gum, as I shall hereafter describe. 

" The following method I much prefer to the string and weight 
above mentioned. Take a piece of annealed iron wire, of medium 
size, and twist it tightly around the tooth, and as near its neck as 
possible, leaving the ends half an inch long, and projecting from the 
buccal side of the tooth ; lift it off carefully, and, having applied the 
rubber, hold it on with one hand, while with the other you place the 



LOCAL TREATMENT OF DENTAL CARIES 



315 



wire in position over the rubber, holding that with your finger till, 
with a large plugger, you push it down on the tooth all around, 
getting it to catch at some point, if possible ; then, holding it down 
with the plugger on the lingual side, push the projecting ends or 
'handle' down close to the gum; place finger or thumb upon it, and 
you are 'master of the situation.' 

"The foregoing applies especially to partially developed inferior 
molars. If, as is often the case, a thick lip of gum projects over the 
posterior part of the grinding surface, and is too stiff for the rubber 
to push back, I excise it and proceed as before. In the great ma- 
jority of cases, however, with these teeth, there is no difficulty in 
causing the rubber to retain its place, by carrying floss silk, single, 
double, or triple, down between it and the posterior approximal 
surface of the tooth ; and if there be a tooth in front of it — which in 
such cases should also be embraced by the rubber — passing the floss 
forward from each side, and making it bind around the tooth by 
crossing it between the two anterior to the one operated upon. 

" But when these teeth are so little developed as that the difficulty 
of retaining the dam upon them will not be obviated by either of the 
just-described methods, I employ the following : 

Fig. 98. 




" (No. 7.) Form a wide clasp of thin gold, or other metal, to fit 
the tooth, rounding the ends somewhat, and letting them slip past 
each other ; let it be a trifle flaring from its lateral centre to each 
edge. The lower side is flared because that portion of the tooth 
which is below the gum line is larger than that above it, and the 
upper flare is to retain the rubber; or, if preferred, the upper flare 
maybe represented by a wire soldered around the edge. (No. 3.) 
Slip this clasp down upon the tooth as far as possible, letting it 
penetrate between the tooth and gum, and proceed to apply the 
dam to this clasp, after which pack the space between the tooth and 
clasp with spunk, for the purpose of damming out any moisture 
from that direction; when, with a finger upon the top of the clasp 
as a security for its retention, proceed to accomplish the now ren- 



316 ORAL DISEASES AND SURGERY. 

dered simple operation of introducing the gold. And just here let 
me say that this 'spunk' that we use is invaluable for stopping, 
under pressure, any leak — unless it be a very large one — which may 
occur during an operation from an inadvertent puncture of the rubber. 
I do not wish to omit mentioning, at this point, and for these opera- 
tions, a little instrument that I use very often. It is simply a 
broken excavator bent into the shape, or nearly so, of a very large 
but short-turned corkscrew plugger, the curve fitting the posterior 
surface of the tooth, and the part resting upon the gum, at that point 
filed to a flat surface. It is held in the left hand throughout the 
operation, and in the position indicated, there being one for each 
side of the mouth. It is very valuable in those cases where we have 
the combined difficulties presented of a very unyielding gum and 
conical shape of the tooth's crown. 

"At least as difficult cases as these to control are those of gum 
cavities, whose edges are below the gum line, and for them I have 
several appliances, according to their position. We will consider, 
first, an inferior molar, with a gum cavity, large or small, upon its 
buccal surface. I have for such two or three clasps, of such con- 
struction as I shall immediately describe, with sufficient variation 
in their shapes to comprehend the more pronounced corners and 
angles of all molars. 

" (No. 6.) This appliance is an open clasp, formed from clasp-gold 
or steel, with the ends left wide and heavy on the lingual side of the 
tooth, which ends are to be turned outward at right angles to the 
clasp, for a length of say three-sixteenths of an inch, leaving a short 
space between the two. A hole is drilled through one of these pro- 
jecting ends for the easy play of a short and thick screw, and a thread 
cut in a corresponding hole in the other, to engage with the thread 
on the screw. This is, as is apparent, for the purpose of fitting the 
clasp tightly to the tooth. The upper edge of the clasp is to be cut 
away on the buccal side, leaving it the width of an eighth of an inch 
or less ; the upper side of this turned outwards, and the lower side, 
which is to engage with the neck of the tooth, finely serrated. On 
the upper side of this buccal portion is left standing a little ear- 
shaped piece with a dent in its centre, which is to be turned down 
to a horizontal position, and is for the purpose of carrying down this 
portion of the clasp, under the pressure of an instrument held in the 
left hand, with its point resting on the ear-piece. The whole clasp 
should be formed in such a manner as that, when in position, the 
lower edge of this buccal side shall dip slightly below the correspond- 



LOCAL TREATMENT OF DENTAL CABIES. 317 

ing edge of the lingual. In applying it, if the buccal contour of the 
tooth be irregular, the clasp should be fitted somewhat to these 
irregularities with the pliers before putting on the rubber; then 
apply the dam, put on the clasp, and, after stretching the rubber to 
the edge, hold it and the clasp in position while you turn the screw 
on the lingual surface and snugly fit the clasp. It will be found 
necessary, in most cases of this nature, to hold the clasp down, as 
before described, with an instrument, throughout the operation, 
though it may sometimes be dispensed with. This is more espe- 
cially adapted to gum cavities in those teeth whose buccal contour 
at the gum line is either very convex or very irregular. 

" (No. 5.) Where, however, the tooth presents aflat surface at this 
point, I have a clasp of thin steel, very wide, and going over the 
tooth from lingual to buccal surface, with very delicate teeth cut on 
the extreme ends, which are turned in, as shortly as possible, to a 
right angle. Opposite the cavity the clasp is cut out, leaving the 
smallest possible rim ; the external edge of this is to be bent up 
towards the clasp till that portion which was next the gum is 
brought to a little above a right angle ; the inside edge of the rim 
is to be serrated, and is to engage with the tooth, below the edge of 
the cavity. On the outside of the rim, next the gum, is left a small 
ear, precisely similar to the one described on the last fixture, and 
for the accomplishment of the same end. (Nos. 5 and 4.) This 
style of clasp is equally applicable to labial or buccal gum cavities 
on all teeth, with, of course, the shape modified to suit such cases. 

" For the front teeth, and particularly the lower ones, there are 
some cases which this will not reach. For such I employ two or 
three patterns of the following. (No. 1 ) Cut from a piece of plate, 
of medium thickness, a form resembling the inverted letter Y, with 
a square top, and of such length as that, when laid against the tooth 
with the ends pointing towards the gum, they shall reach nearly to 
it on each side; to these ends solder a small but stiff rim, running 
in front of the tooth at a slight angle downwards to the main piece, 
the ends of the latter having been previously bent inward some- 
what, in order to freely expose to view the cavity between them. 
In the square top of the main piece are drilled two holes for the 
purpose of attachment to the tooth. The whole is applied by 
putting on the rubber, carrying down the approximal edges, as in 
all similar cases, drawing the rubber to the cervical edge and super- 
posing the holder upon it — after looping a piece of floss silk through 
the holes in the top, and passing the loop over the tooth, and tying 
firmly to place. 



318 ORAL DISEASES AND SURGERY. 

" Where the cavity is an approximal one, and extends under the 
gum, the wire clasp before mentioned may be made useful for hold- 
ing the rubber and gum away from the cavity, by threading between 
the teeth, and twisting it on, after the rubber has been applied ; or 
it may be put on before the rubber, leaving the twisted ends pro- 
jecting ; and, in carrying the rubber to place, pass through the hole 
which is to embrace this tooth both the tooth and ends of the wire, 
and bring the wire above the rubber with a small burnisher. 

"When teeth have been wedged apart for the purpose of filling 
approximal cavities, they are always more or less loose and tender, 
and it has always been my practice in such cases to insert a thin 
wooden wedge at the necks, before commencing to operate, for the 
double purpose of keeping them firm and apart while operating. 
This wedge, when the dam comes to be applied, may be left in its 
position, and the dam superposed upon it, or it -may be taken out 
and placed over the rubber. The great objection to the latter 
method has been, that the resiliency of the rubber, together with 
the movement of the teeth in operating, does not admit of a simple 
wedge's keeping its place. This difficulty has been remedied by a 
little device, suggested to me by Dr. Varney, of this city, and which 
consists in inserting between the weclge and rubber a T-shaped 
washer, of very thin metal, the long arm being of a width to pass 
readily between the teeth, and the inside of the short ones cut to fit 
the buccal corners of the teeth between which it passes. This 
appliance is also of great value for exposing all approximo-buccal 
cavities. 

" (Xo. 2.) When, however, the cervical edge of the cavity is so far 
beneath the gum, and the gum on either side of the approximal 
surface is so hard and unyielding as that this method shall prove 
insufficient to surmount the difficulty, recourse is found in the fol- 
lowing: cut a strip of clasp plate, of medium thickness, to a width 
approximating that of the lateral diameter of the tooth ; drill two 
small holes across and near the end ; then bend the strip just below 
the holes to an angle of forty-five degrees or thereabouts, and of a 
sufficient length to reach across the space and to the cervical edge of 
the cavity. (In special cases, — for instance, if the crowns are long, — 
it is well to bend up at a slight angle this end for the one thirty-second 
of an inch, for the purpose of obtaining the essential requisite in the 
premises, viz., a flat surface pressing the rubber downward and at 
the same time springing against the neck of the tooth below the 
cavity, as, if these are not complied with, the teeth will not be held 



LOCAL TREATMENT OF DENTAL CARIES. 319 

firmly apart, or the rubber will be pressed away from tbe neck of the 
tooth, causing leakage.) This end is to be beveled to an edge, and 
slightly serrated, to prevent it slipping. Now apply the rubber, and 
after looping a piece of floss silk or fine wire through the holes, lay 
this part of the spring against the approximal surface of the adjoining 
tooth ; push the rubber down to the edge of the cavity ; superpose 
upon it the toothed end of the spring, and make fast by tying or 
wiring tightly around this adjoining tooth. As has been hinted, 
this appliance will, if properly made, hold the teeth firmly wedged 
apart while filling, — a very essential matter, and one that must in 
such cases always be accomplished in some manner, as the dam 
tends to add to their natural inclination to return to the position 
which they occupied before wedging. 

"The matter of turning under the edges that stand up against the 
teeth is so essential, that I would reiterate the necessity of its 
accomplishment in all cases and around each tooth ; otherwise there 
will be leakage at these points, the unturned edge being precisely 
analogous to an open valve and the turned edge to a closed one. 

''While upon the subject of gum cavities on the labial surfaces of 
the incisors, I omitted to mention the following: if the cervical edge 
is but a short distance beneath the edge of the gum, and still so far 
as that the dam, unassisted, will fail to keep its place, I employ an 
instrument — of which I have several shapes — held in the left hand, 
for the purpose, the essential part of which is simply a wide, flat 
blade, with the edge on its end hollowed out to correspond to the 
contour of the tooth's neck; this concave sharpened, and, if thought 
proper, finely serrated, it will be found more convenient to hold, if 
that side or end of the concavity which is farthest from the hand 
that holds it is left longer than the other. The particular shape 
which I find best adapted to all cases is that of an enlarged hatchet 
excavator. 

"In regard to the quality or thickness of rubber best fitted for 
our purpose, it is greatly a matter of taste The thinner qualities 
require more skill in their use than the heavy ones, as after the 
application of the former, if great care is not constantly exercised, 
particularly in cavities anywhere near the gum, it will be stretched 
away from the tooth, and the operation flooded. On the other hand, 
far more delicate presentations are effected through it than by the 
heavier; besides which, it passes more readily between teeth which 
are nearly approximated : indeed, it may be laid down as a rule, in 
this connection, that it will follow floss silk into any position. For 



320 ORAL DISEASES AND SURGERY. 

general use, however, if the thinnest were numbered 1, and the 
thickest 4, my recommendation would be number 2. 

"Any sized piece may be used, but that which will be found best 
for most cases is, perhaps, four or five by six inches. And though 
it may often be applied in such a manner as that the patient may 
close the mouth and swallow, it will generally be found more con- 
venient for the operator, and to accord better with the taste of most 
patients, to spread a large napkin or towel over the shoulders, for 
the purpose of taking up the saliva as it leaves the mouth; or a 
double-valved saliva-pump may have its nozzle resting in the mouth, 
the rubber tube from which leads to the spittoon, when an occa- 
sional squeeze of the air-chamber will effectually keep the mouth 
free from saliva. 

" The ends of the clam may be held back out of the way by means 
of a little fixture, invented, I think, by Dr. Goggswell, which is simply 
an elastic band, with a slide-clasp on each end for seizing the 
end of the rubber, and a contrivance, in addition, on one end, for 
drawing the band tight, the latter passing around the head. Another 
method is, to catch the rubber with small hooks, at the end of a 
piece of twine, on each side, and crossing the ends, to which are 
attached small weights, on the head-rest behind the head. 

"When one uses the dam very much, he will find that the con- 
stant pressure of the floss silk under the nail of the forefinger — 
which is the one most used in applying the dam — will keep it in a 
constantly sore and irritated condition. To obviate this, I cut off 
an ordinary thimble, so that it shall form a cap for the end of that 
finger, and then serrate it deeply over the whole end. It can be 
taken off as the fingers are required to apply the dam from tooth to 
tooth, by turning that finger to the centre of the hand, and reapplied 
in the same manner when the floss is taken up.'' 

In connection with this paper may be exhibited an appliance 
invented by Dr. Forbes, Fig. 99. 

Fig. 99. 




" The use of this instrument is to force the rubber ddwn be- 
tween back teeth, evenly to the necks, without tearing it ; and also 
to pass the tying cord around molars more pleasantly than can 



LOCAL TREATMENT OF DENTAL CARIES. 321 

be done with the fingers. When a very high strain is needed, 
fix the cord in position with half a turn around the button, and 
tighten it while pressing the points of the fork between thumb and 
finger." 

Operators whose experience with the rubber dam has been large, 
recognize that few cases will be found where the ligature of thread 
or silk cannot be made to fulfill all indications in the way of securing 
it in position. In the use the author has himself made of this means, 
he has certainly been able to accomplish his ends without exercise 
of the ingenuity exhibited in the paper quoted: as a study, how- 
ever, the suggestions must be found to have much value to the 
inexperienced. 

A cavity before prepared to receive a filling is to have a direct 
drying; that is, all the moisture it contains is to be absorbed. To 
this end, what is known as bibulous paper is commonly used. 

A means widely employed, and highly extolled, is the application 
of dry heat; this is to be effected by the use of an air syringe with 
heated bulb. Fig. 100, showing such an instrument, will explain 
the manner of its use at a glance. 

Fig. 100. 




Hot-air syringe. 



In filling the proximal face of a tooth when the napkin is de- 
pended on to keep the part dry, attention is necessarily directed 
to the oozing from the mucous crypts immediately surrounding the 
neck. To control this, some operators depend exclusively on pads of 
absorbing-paper held as closely as possible to the part. A mode 
more convenient, however, and more reliable, consists in passing a 
wedge of soft wood between the cavity and the gum, allowing it to 
press hard against the latter. Still another excellent means is found 
in including the neck of the organ in a ligature of heavy silk or 
other thread, tying it as tightly as possible and thrusting it closely 
against the gum out of the way of the operation. Another mode 
yet is found in the cauterization of the gum, a strong solution of 
iodine, nitrate of silver, or chloride of zinc being used. The me- 
chanical means suggested, however, will be found the most satis- 

21 



322 ORAL DISEASES AND SURGERY. 

factory to employ, as no ulterior ill consequences are to be appre- 
hended. 

The Filling. — Non-adhesive gold is used in four forms : in cylin- 
ders, in plates or mats, in ribbons, and in twists; these forms being 
also frequently conjoined in a single cavity. 

To make a cylinder, a sheet or portion of a sheet of foil is folded 
upon itself until a ribbon is obtained, which, in width, is to be some- 
what greater than the depth of the cavity in which it is to be used. 
The ribbon is converted into the cylinder simply by rolling it around 
a common pin or brooch ; this is accomplished in a moment by laying 
the ribbon lengthwise along the index-finger of the left hand, and, 
with the thumb resting upon the pin, which is laid across the initial 
extremity, revolving it toward the palm. 

To make a plate or mat, first convert the sheet into a ribbon as 
before, of such varying width as may be required; next back-fold 
into the required length. 

To make a ribbon, proceed as has been directed. 

To make a twist or rope, first convert the sheet or portion of sheet 
into a very loose ribbon; twist this now upon itself cork-screw fashion. 

Referring now to individual cavities, which will serve as studies 
to direct the ingenious hand, attention may first be given to such 
simple forms as are represented by round holes, — cavities alluded 
to as being common to the crowns and sides of the molar teeth and 
to the posterior faces of the incisors. To fill cavities of this class, 
the cylinder naturally suggests itself. Selecting one of a size which 
may be carried readily to the bottom, it is, after being placed, 
to be laterally expanded by a wedge plugger carried through its 
centre, or otherwise may be condensed in mass against the wall of 
the cavity. The space thus made is to be filled by a second cylinder 
of convenient size, the wedging to be repeated, and the introduction 
of cylinders to follow, until no more space may be obtained. 

Plates are found, in the beginning of an operation, to conveni- 
ently replace the cylinder where crown cavities are large and of more 
or less irregularity in form. They are used precisely as the cylinder, 
being carried into position by means of the foil-carrier, and con- 
densed carefully and accurately against the immediately neighboring 
wall. The plates following the first may either be arranged around the 
cavity, thus making as it were a gold cylinder into which cylinder 
after cylinder as before directed is wedged, or one plate may be 
condensed against its fellow until in this way the cavity is full. 



LOCAL TREATMENT OF DENTAL CARIES. 323 



Filling a cavity with the ribbon, although highly Fig. 101. 
extolled by many, is associated with much more trou- 
ble than the use either of cylinders or plates. To 
manipulate gold so prepared, the operator, after 
carrying the initial extremity to the bottom of the 
cavity and fixing it by any convenient means, — generally 
by holding it with an instrument held in the left hand, 
or confiding the task to an assistant, — folds upon this, 
first, layer after layer, making the bend at such distance 
above the orifice of the cavity as considers the con- 
densation to which, later, it is to be subjected, and 
which, if properly done, is to afford a solid surface 
that shall not be sunk below the margin when the 
necessary filing and polishing shall have been com- 
pleted. 

Twists or ropes are used precisely as the ribbon, 
fold after fold being bent and carried into a cavity until 
no more may be received. It is more common to con- 
fine the use of the rope to small cavities, such as are 
found on the proximal faces of the anterior teeth, 
although operators are met with who employ gold in 
such form exclusively. 

A modification on the use of the ribbon and rope, as 
just described, consists in wedging the centre during 
the progress of the filling. The operator first gets his 
cavity loosely filled ; then, leaving the rope as related 
with the last fold, he wedges the gold against the parietes 
of the cavity. This secondary cavity is then filled by 
turning the rope into it, as in the first instance. 

Another study, which may serve as the demonstra- 
tion of a second class of fillings made of non-adhesive 
gold, are the cavities in the anterior teeth, proximal 
faces. As the filling of all such cavities is on a common 
principle, we will take the incisor, Fig. 78, right side, 
as seen prepared. 

To fill this tooth, — being made ready as under- 
stood, — the operator takes a leaf of gold, preparing with 
it, besides a rope, a number of plates. The plates 
he arranges upon his tray or table, having various 
sizes, which he has laid in such convenient rotation 
that, without search, he may be able to pick up such 
size as required. The rope may be cut into small 
pieces. The gold thus made ready, the next require- 



til 



324 



ORAL DISEASES AND SURGERY. 



ments are the necessary instruments. Fig. 102 exhibits a set of plug- 
gers, designed by Dr. W. G. Redman. Possessing these instruments, 
an operator will find himself able to introduce and pack cylinders, 
plates, and ropes in the various cavities to which they are found 
adapted. 

" These cuts represent thirty of the most approved points. They 
can be made with handles to suit the purchaser. A half-inch ivory 
or ebony handle is recommended. Nos. 1 to 1 (serrated-foot instru- 
ments) are lateral condensers for all cavities. Nos. 8 to 11 (smooth- 
foot instruments) are used in the same cavities and in the same 
manner, but not until the cavities are nearly full. Nos. 12 to 24 are 
all approximal condensers. No. 25 is for anterior approximal 
cavities, molars and bicuspids. No. 26 is for posterior approximal 
cavities, molars and bicuspids. Nos. 27 and 28 are for crown cavi- 

Fig. 102. 




ties, upper molars and bicuspids. Nos. 29 and 30 are for crown 
cavities, lower molars and bicuspids." 

To fill the tooth selected, the operator would take up with his foil- 



LOCAL TREATMENT OF DENTAL CARIES. 325 

carrier a plate of gold of a size suited to an easy introduction into the 
cavity. This plate it is designed to place firmly against the neck- 
surface of the cavity. To so direct and place it, any of the instru- 
ments, Nos. 7, 11, 21, or 28, might be employed. The first piece in 
position, a second plate is to follow, being introduced in like man- 
ner and consolidated against the first. Sometimes, however, and 
particularly where the labial wall of the cavity is delicate, it is 
found best to lay this second plate against this surface, obtaining 
thus increased security against fracture. Plate after plate may 
now be added until the cavity is full, or, if preferred, the cut 
rope may be used, piece after piece being carried and wedged into 
place. 

Another plan of using the plates in cavities of this character con- 
sists in first lining with them the circumference and afterwards 
wedging the cut rope into the centre. 

Still another plan that is found at times convenient consists in 
placing one plate against the neck-wall, and a second in that portion 
of the cavity nearest the cutting edge of the tooth, wedging now the 
cut rope, or other plates, between these. 

Another plan still is found in using a twist or rope of gold, as 
directed in the case of crown cavities, turning into the cavity layer 
after layer, until no more can be entered. This formerly was the 
almost universal practice, being now, however, replaced by adhesive 
foil, a means shortly to be described. 

In operating on a cavity of such position as we now consider, the 
head of the patient is to be thrown back, the mouth looking upward. 
The operator stands at the right side of the chair, while the fingers 
of the left hand support the tooth, as may be found required for the 
comfort of the patient. 

The chair upon which a patient sits is to be of such height of seat 
that the head is brought on a level with the breast of the operator. 
For such purpose there is the greatest variety of construction. (See 
Catalogues.*) A. head-rest, applicable to almost any chair, and 
which will be found of every desired convenience to the army sur- 
geon and to the practitioner who may not desire to purchase a costly 
chair, is an invention of Dr. 0. C. White. This rest " makes its 



* Catalogues containing illustrations of almost every instrument and appli- 
ance used in operations connected with the teeth are to be obtained, free 
of cost, by addressing any one of the prominent manufacturers of dental 
goods. 



326 



ORAL DISEASES AND SURGERY. 



Fig 103. 





own fastening to almost any style of chair, sofa, lounge, or settee. 

It has full movement in 
all directions, on a scale 
for a tall person or for 
a child, and is securely 
fastened by turning a 
single thumb-screw." 

The accompanying 
cut represents the rest 
applied to a common of- 
fice-chair, with dotted 
lines showing its movements ; and 
the rest, on the same scale of size, 
folded up, to occupy but little space, 
either for transportation or to lay 
aside. 

Weight, 4| pounds. 
Upon the operating-tray should 
always be found pellets of bibulous 
paper and one or two twists of cot- 
ton. A small bottle of chloride of 
zinc, or of Monsel's solution of the 
persulphate of iron, should also be 
within convenient reach in case of 
slight hemorrhage from an accidental pricking of the gum. Twists 
of cotton are sometimes found of great service in slipping between 
the cavity and the gum when the napkin is used. The thumb and 
finger holding the tooth will also fix and retain the twist. It is to be 
held tightly against the gum. Even more convenient than the 
cotton will be found delicate strips of wash-leather. This latter 
in my own practice I have come to prefer; it absorbs the moisture 
fully, and is more easily kept clear of the cavity, should this be near 
the gum. 

Passing to still another study, we may consider the anterior proxi- 
mal surfaces of the bicuspidati and molars. Referring to the dia- 
gram, Fig. T8, it will be seen that such cavities, when properly ex- 
posed, are converted into those of very simple forms. To fill them 
it is only necessary to employ the mechanical means given. Com- 
monly the operator commences with a plate which he fixes against 
the cervical wall, laying plate after plate against this first one, until 
the cavity is full. Where the cylinder is employed, the principle of 



White's Head-Rest 



LOCAL TREATMENT OF DENTAL CARIES. 327 

introduction and consolidation will be seen to be precisely the same. 
In large cavities of this position, it will be found an excellent plan 
first to bound the cervical and lateral walls with plates, and after- 
wards wedge the cylinders or mats within this golden cavity. 

Posterior proximal faces are commonly much more difficult to fill 
than the anterior. Such difficulty, however, is found most markedly 
influenced by the preparation of the cavity and the state of the 
boundaries of the mouth to be operated in. A deep narrow arch 
with the labial orifice small and tense, and much buccal adipose 
tissue, and with the patient unable or unwilling to assist by keeping 
the mouth well open, will worry the most skillful and experienced. 
On the contrary, in the wide mouth of free and lax orifice, little 
more trouble is experienced than in the case of the anterior. Such 
cavities are filled with the non-adhesive gold precisely as are the 
anterior. 

The use of matrices in the construction of a temporary wall for 
the conversion of such cavities into simple holes has long been a 
favorite means employed by many persons. A very easy and always 
convenient way of making such matrices, and one which the author 
has employed in hundreds of cases with satisfactory success, con- 
sists in breaking off a section of an ordinary separating file having a 
free or uncut surface, and, slipping it between the two teeth, wedging 
it in place. This, as must be seen, is not by any means a complete 
wall, but it will be found to answer a most excellent end, needing, 
indeed, to be seconded only by a reasonably skillful touch to fulfill 
sufficiently well the indications. Such matrices are most conve- 
niently used if the temper is first removed. 

Another mode of making a matrix to apply to an approximal in- 
clined plane consists in taking a delicate strip of silver, and after 
cutting and filing so that it shall half cover the cavity, being bulged, 
however, just over it, wedging it by means of splints of boxwood into 
place: this manipulation forms, as is seen, a limited last wall, but 
such wall is quite sufficient to answer the ends. 

A character of matrix invented by Dr. Louis Jack has attained 
most deserved popularity. A description of its use given by the 
inventor will be readily understood by reference to the cuts which 
accompany. When cavities are of such extent as to complicate 
very much the process of introducing and fixing the gold, these 
matrices, from what might be termed their permanent and full char- 
acter, will be found not only to spare the operator much fatigue, but 
to assist materially in giving form and solidity to a plug. 



328 ORAL DISEASES AND SURGERY. 

"The difficulty," says Dr. Jack, " of correctly filling" the proximal 
surfaces of bicuspids and molars is so universally acknowledged, 
that any means which may render this class of fillings more easy of 
performance, and which may promise more certain results than are 
usually secured, would be regarded by every one as an important 
desideratum. It would also be desirable to reduce the weariness 
which is inseparable from difficult operations on the proximal sur- 
faces of the molars, with which all who endeavor to be faithful are 
familiar. My own experience in this class of cases has been excessive, 
and the constant repetition of extensive proximals has so repeatedly 
exhausted my nervous force as at times to fill me with despair. It 
is therefore a satisfaction to have made an improvement by w T hich 
much of this difficulty is overcome; by which the introduction of 
the gold has been rendered much simpler, more certain, and so man- 
ageable that I must now let others have the full benefit of my expe- 
rience. 

" It will at once be granted, at least by those who have learned 
to appreciate the advantages gained by the use of the mallet, that if 
we had a fixed boundary or wall to the outer side of the cavity, 
having the form required to give a proper shape to the surface of 
the filling, and a sufficient opening to freely introduce the gold to 
every portion of it, the solid filling of the space would be easily 
attainable. 

" I have for some months been working up a method of introduc- 
ing proximal fillings by the use of what may be not inappropriately 
called proximal matrices. It will be necessary first to describe the 
preparation of the cavity, including the modifications in its form 
required to adapt it to the application of the means to follow. 1 
trust to be excused for entering at some parts into what may seem 
excessive detail. To be more clearly understood, and to limit the 
use of technical terms as much as possible, it will be assumed that 
considerable caries is found between the superior first molar and 
bicuspid, involving both teeth on their proximal surfaces, extending 
from beneath the gum to the masticating plate of enamel, but not 
involving the pulp. Everything herein written will apply to the 
treatment of these two cases, leaving the application to other posi- 
tions to be made by the reader. 

" The first step, in case the teeth are in close contact, is to separate 
them, either by pressure, or, as in so extensive caries as is under 
consideration, by a parallel-sided file ; and from this slight separation 
rapidly and freely open by cutting down the enamel at the middle of 






LOCAL TREATMENT OF DENTAL CARIES. 329 

the spnce, afterwards increasing somewhat freely with the chisel 
the inner portion of the opening. Another plan I sometimes pursue, 
where no fracture of the masticating plate has occurred, is to pass 
a small five-sided drill until it fails to meet with resistance, increasing 
by a larger drill ; and from these two half-circles I cut in either 
direction with suitable chisels by carefully splitting down the ena- 
mel, — first the masticating portion, — and continuing until a free 
space is secured on the inner side ; then more carefully opening 
toward the buccal division, until a slight space is made at this 
point. The file may be used at this stage to further open the space, 
and in bringing the surfaces into proper shape and smoothness. 
When the cavities are so large as is assumed above, there will 
usually be found so much disorganization of the enamel as to render 
necessary so much cutting to procure a healthy surface as will open 
a space abundantly large for the subsequent work. If more is needed, 
it is secured by wedging j in any case a separation as large at the 
lower part as a No. 7 Froid file, and at the cervical part as a No. 3, 
is easily secured. The buccal space should be but slightly wedge- 
shaped, and somewhat smaller than the palatal, for reasons which 
will appear in the proper place. 

" After removing the softer caries, the walls of the cavity are 
prepared for the reception of the filling; the overhanging masti- 
cating plate being first cut away in a circular form on a line with 
the bottom or pulp wall, so that by direct approach every part of 
the cavity is accessible to slightly curved or even straight instru- 
ments. This opens the whole cavity to view. The instrument best 
adapted for this purpose is the gouge-shaped chisel, which cuts with 
exceeding keenness, and produces the form desired at this part. 
The removal of this portion of the enamel is an important and indis- 
pensable step in the improvement I am pursuing. It is practiced 
by the better operators to a somewhat less degree, and is in many 
cases an advantage to the organ. No other argument to defend 
this course need be used than that in these fillings, so difficult of 
execution, everything subservient to better performance must be fol- 
lowed out which is not injurious to the strength and preservation 
of the organ. It will often prove true here, as elsewhere in surgery, 
that something must be taken to save the remainder. 

" The cervical wall is now cut at a right angle to the proximal sur- 
face, taking care to remove from the surface of the tooth beneath 
the gum any half-decomposed enamel which may be present at this 
part. No retaining groove or pits are needed on this wall. 



330 ORAL DISEASES AND SURGERY. 

" The buccal and palatal walls are next smoothly cut, and on the 
side of each, where they have sufficient strength, a shallow, round- 
bottomed groove is made the whole length, and terminating at the 
very surface of the masticating plate of enamel. The outer retain- 
ing groove should be near the margin, to avoid any approach to the 
pulp ; the inner one should be nearer the bottom of the cavity, that, 
in the subsequent cutting away of a portion of the palatal wall in 
the finishing process, the hold of the gold may not be obliterated. 
The instruments best adapted for this grooving are made by filing 
a straight point quite round and small, then bending at a suitable 
angle, and shaping so as to have the edge at the inner side of the 
curve. Instruments of this form are better adapted for cutting the 
hard dentine and enamel than any others, for the reasons that they 
may be made harder than usual without danger of breakage ; they 
cut with more keenness, do not chatter, leave the surface without 
sharp lines, and in grooving each cut follows in the last with cer- 
tainty. They are directly reverse in form to the hoes and exca- 
vators in general use. 

" The pulp wall of the cavity is not altered in the form it presents 
after the removal of the caries. 

" The next and very important step is to remove the sharp corners 
of the mouth of the cavity, and at every part well polish it with 
pumice-stone ; this facilitates the passage of the gold over the sur- 
face and the perfect contact of the foil with every part. This polish- 
ing is rapidly done by rotating a piece of boxwood armed with 
pulverized pumice. 

" Selection is now made of one of the appliances figured below, 

which are intended to give form to the outer surface of the filling, 

and are called matrices for this reason. These little affairs are made 

of a variety of shapes, sizes, and thicknesses. They are formed of 

slightly wedge-shaped pieces of steel, and are, as the cut 

^____, designates, hollowed out at their thicker edge, which 

^HF depression terminates at the thinner edge. At the part 

of the depression designed to give shape to the buccal 

edge of the filling the cut is generally abrupt and deep ; at the inner 

portion it is more shallow and more inclined. It will be observed 

that the depression widens as it passes toward the thinner edge to 

follow the usual form of proximal cavities.* The lower and thin 

* In Fig. 104 the boundary of the right end of the depression should be 
similar to the other end. 



LOCAL TREATMENT OF DENTAL CARIES. 331 

edge is rounded, to outline the curved margin of the cervical wall, 
and to effect pressure upon either the gum or the appliances used 
to stop the escape of mucus and blood from this tissue. 

" The plane parts of the face are file-cut or coarsely draw-filed. The 
reverse side, represented at Fig. 105, and which for convenience of 

description is divided into three sections, is in 

^ t .i. + + u Fig. 105. 

most cases plane and smooth, excepting at the 

section c, which is file-cut. It is often necessary a ^ T"^~0 

to have this side in two surfaces ; one, section c s^~~~*j 

a, parallel with the plane parts of the face, and 
from this point inclining to a thin edge. A very desirable form is 
to have section c bent backwards to follow the incline of the proxi- 
mate tooth beneath the gum. At each end a square cut is made to 
fit the plier ends represented at Fig. 106. After being 
formed, they are protected from oxidation, heated to red- 
ness, plunged in the cold bath, and temper drawn to near ffi 1\ 
blueness ; after polishing the depression, they will be ready 1 

for use. Quite a number of pairs are necessary to meet 
the requirements of the differing cases ; but for the ordinary-sized 
simple proximal cavities, a dozen pairs, varying in width, in thick- 
ness, and in size of depression, are all that I have found necessary. 
Fig. 104representsthelargestsizerequired, those most in use not being 
more than from one-half to two-thirds this width and thickness. The 
character of these modifications will depend somewhat upon the de- 
sired end, since either a flat, contour, or excessively convex surface 
may be produced at the pleasure of the operator, or to suit the needs 
of the individual operation, by varying the form and depth of the 
depression. It is also occasionally necessary to have a matrix of 
unusual form to meet special cases, where the space is extremely 
great, or where, from the fracture of the outer plate of enamel, a steel 
one will not remain in position ; for this purpose I have found hard 
boxwood to answer quite well. Silver also, in such cases, will occa- 
sionally be found useful. I sometimes take an impression of the 
immediate part to assist me in the fabrication of a suitable appli- 
ance. I have also some double-faced ones, w T hich are so formed as 
on one adjustment to allow both cavities to be filled. For isolated 
teeth having large posterior cavities, a ring of silver may be used, 
carrying out the same principle in forming the portion which bounds 
the cavity. I have used the same plan in buccal cavities. 

" The selected matrix should, at the convex edge, be a little thinner 
than the space between the teeth at their closest part by the gum ; 



832 ORAL DISEASES AND SURGERY. 

it should pass above the edge of the cervical wall, and should con- 
form at this part to the contour of the tooth ; the lower and thicker 
edge should reach nearly to the masticating surface, and this edge 
should not entirely fill the lower part of the space ; above all, the 
depression at every part of its border should extend slightly beyond 
the edge of the cavity. 

" After having secured the cervical part of the case from the en- 
croachment of moisture, which I do by various means, — viz., the 
wedge of wood, little rings of india-rubber, the string dam, short 
pieces of waxed twine, of such size as to remain firmly in place 
when drawn between the teeth, the application of dilute chloride of 
zinc, etc., or a combination of two or more of these means, — the 
matrix is taken up in the pliers (Fig. 10f>), and pushed upwards until 
it presses upon the gum or the appliances, and until it impinges 
tightly between the teeth. It is now wedged firmly against the 
tooth to be operated upon, with little boxwood wedges ; these secure 
it in place during the packing. When the matrix passes up to the 
proper point, the wedging towards the cavity throws the lower edge 
against and somewhat beneath the projecting swell of enamel of the 
neighboring tooth, which adds to the security. However tightly 
the matrix may fit between the teeth, it will not frequently retain 
its fixedness unless securely wedged. Boxwood answers for this 
purpose better than any substance I have employed, for the reason 
that it is so hard as to be unyielding, and on this account also does 
not require to be more than pushed into the space. The wedges 
should be made in quantities for convenience of selection. The 
pliers (Fig. 106) are adapted to their introduction. 

" In case the adjoining teeth are not in contact, it is always neces- 
sary to introduce a w T edge between them, to give greater firmness 
to the teeth and less discomfort to the patient. In all large cavities 
I fix the matrix previous to introducing the napkins. Where the 
rubber-dam is required, it precedes this appliance, which may aid in 
keeping the rubber in place. 

" For the small cases, the drying is done first, the napkins applied, 
and a hard rope of bibulous paper is passed against 
the gum, followed by the matrix. Fig. 107 represents 
the appearance of the parts at this stage, except the 
wedges, which are not shown. When the cavity is 
now examined, it will be found to present an open 
mouth, formed by its curved lower edge of enamel, 
and by the boundary of the matrix, through which funnel-shaped 




LOCAL TBEATMENT OF DENTAL CARIES. 333 

opening every part of the space is easily seen and directly touched. 
The case is now ready for the reception of gold. 

" I use for the upper half or more of the filling, ribbons of Nos. 4, 5, 
or 6, of slightly adhesive gold, but not annealed. These ribbons are 
made of one-fourth to whole sheets of foil, depending on the size of 
the space, and then folded into blocks, varied in length by the 
requirements of the case. For the lower third I prefer rolled gold 
of No. 20 to 30, of the most adhesive character, and annealed. I 
also use for this part in many cases 'Eureka gold filling,' No. 15, 
with the greatest advantage, taking up one or more of the shreds, 
and working them in wherever needed. The first block or mat is 
passed up toward the outer border, until it reaches the cervical wall, 
when the lower end is pushed into place, and fastened by pressure 
into the upper part of the retaining groove. The second piece is 
secured in the same manner in the inner or palatal groove ; a further 
piece is forced between the two, and directly against the cervical 
wall. When a sufficiency of gold is placed upon these parts to save 
the tooth from contact of the points, the gold is securely malleted 
against the walls at all points, paying particular attention to the junc- 
tion of the tooth with the matrix. In this way I proceed, success- 
ively introducing and malleting, until the cavity is two-thirds filled, 
nor hastening further at any point, unless the assurance is reached 
that the gold is perfectly consolidated. At this point I commence 
and continue the employment of heavy gold, the first pieces of which 
should be well fixed in the gold previously introduced at the parts 
over the retaining grooves, and also worked well into the founda- 
tion. It is now a simple matter to fill up the remainder with 
quickness. 

" In case there should happen to be an encroachment by moisture 
at or near the close of the packing, the gold may be made smooth on 
the exposed surface, dried, and the latter part inserted, with all the 
characteristics of a separated filling. The form of the last third is 
such that, if inserted with dryness, no portion can escape. The 
matrix should now be removed. 

"It will be found, if the selection and adjustment of the matrix have 
been correct, that very little filing and cutting down of the plug will 
be required, and, in case the packing has been carefully performed, 
that the gold will be solidly condensed at every part. It will also 
be noticed that, while the gold is solid, it will not have become 
hardened in temper on the proximal surface, but yields laterally 
under the burnisher, not unlike lead or tin. 



334 ORAL DISEASES AND SURGERY. 

11 1 must at this time call attention to the importance of the adapta- 
tion of the filling material to the cervical wall, which it requires no 
words to show will be secured by this method. There can hardly 
be a question that the general failure of proximal fillings is due to 
one or both of two causes, — the imperfect preparation of the cavity, 
and the want of solidity and adaptation of the gold at this part. 
When the filling extends to the gum or beneath it, and the teeth are 
not permitted to come into apposition here, this portion of the tooth, 
when well protected, is least liable to decay, as this is not the place 
where caries usually commences. And when the filling reaches to 
the cementum, the recurrence of caries is still less to be appre- 
hended, since it is a clearly established, but apparently overlooked, 
principle that this structure is the least liable of the dental tissues 
to destruction. It will be noticed how seldom failures occur along 
the cervical edge of gutta-percha fillings, even when carelessly per- 
formed. These considerations have been forcing many to seek for 
better means of securing adaptation, solidity, and smoothness at 
this part. 

" The instruments for introducing the filling are of simple forms 
and direct action, but they should be in fine condition, — that is, the 
points should be well serrated, and sharp. The only im- 
portant modification needed are some pairs of mated plug- 
gers, formed as at Fig. 108, in which one side of the edge is 
considerably longer than the other, which longer side, in 
malleting, is constantly kept against the matrix; this effects 
the greatest pressure upon the margins, and secures with 
positiveness the perfect fullness and the proper consolida- 
tion of the gold at these parts. Several sizes and varied 
curves of this point are required. 

" The finishing of the case is not different from the usual 
course pursued. In my own practice I open still further the inner 
portion of the space, which is easily done with chisels and suitable 
files. The peculiar form of the depression in the matrix produces a 
space which is considerably greater on the inner side, and which 
may be increased at pleasure. In many cases, where the tendency 
to caries is very great, I chisel quite freely from the inner plates 
of enamel, doing this after both the adjoining fillings are inserted, 
cutting down both gold and enamel together, allowing the fillings to 
touch only at the prominent outer part. The result is then an imita- 
tion of the exceeding!} 7 oval bicuspid ; of the immunity from decay 
of which all must have seen examples. 




LOCAL TREATMENT OF DENTAL CARIES. 835 

" Fig*. 109 represents a transverse section of two cases at a point 
immediately above the grinding surface, which ex- 
hibits the outline of the form of the cavity and 
finished surface of the gold. 

" In full confidence, founded on sufficient trial, I 
claim that this method of filling proximal cavities 
overcomes several of the chief difficulties and de- 
ficiencies hitherto experienced, as well as enables greater facility of 
performance, and the security of excellent results. 

" I have not mentioned a number of secondary advantages, which 
I must leave to that class of operators who alone will adopt this 
plan, and who are of such capacity as to seize upon all the favorable 
features of this method, and who will make the indefinite application 
and improvements of which it is susceptible. 

" In my own hands it has enabled me to execute with greater ease 
and with more certainty the large distal cases than I was previously 
capable of accomplishing, under favoring circumstances, in fillings 
of equal size on the mesial surfaces." 

Referring again to the diagram, Fig. 78, attention may be directed 
to the filling of the very irregular crown cavities represented, two of 
which are shown running, upon the first molar, into the lateral walls. 
In filling such cavities, the operation is to be accomplished without 
much difficulty by introducing first into either extremity (which has 
been prepared as described) cylinders or plates of gold, and, after 
securing the fixedness of these, packing subsequent plates or twist- 
pellets one after the other, until the line of association is full. It is, 
however, in instances of this kind that the use of the adhesive gold 
is felt to be almost a necessity. Working gold so prepared and 
understood, one would scarcely be likely to depend on the mode 
just described. 

A last study that may seem necessary to make in connection with 
the exclusive use of the non-adhesive gold, may be directed to the 
cavity seen in the crown face of the wisdom tooth, Fig. 78, right 
side. This cavity has a complex relation only, however, from the 
fact that it is seen to be half covered by an operculum of gum tissue. 
In filling such a cavity (or, indeed, rather would it pertain to the 
preparation of the cavity), it is found necessary to uncover entirely 
the parts : to accomplish this, tufts of cotton or sponge may be 
thrust between the tooth and operculum, which tuft, in the process 
of swelling, will sometimes remedy the trouble by thrusting the 
gum beyond the posterior wall of the tooth, around which it may 



336 ORAL DISEASES AND SURGERY. 

contract, and so afterwards be held. A much more common require- 
ment, however, is the entire removal of the fleshy lid by amputa- 
tion, the part being lifted upon a tenaculum and snipped off with 
scissors or bistoury. The operculum removed, the cavity is at once 
converted into the most simple form. 

Adhesive Foil. — Adhesive foil, as implied in the name, is sticky. 
Two leaves of such gold pressed together with a very moderate de- 
gree of force will adhere with such tenacity that they may not after- 
ward be separated. 

To fill a tooth with adhesive foil, an absolute dryness is essential 
to success. To prepare such gold for use, it is desirable that the 
operator first wash his fingers with alcohol : this cleans and dries 
them thoroughly. The foil is now to be prepared according to the 
number used: being folded loosely into twists or cut into strips. 
In my own practice, confining myself almost exclusively to what is 
known as No. 5, — that is, a leaf of this number of grains in weight, — 
it is my habit first to fold the full leaf ribbon-fashion, making the 
folds very loose, and about an inch in breadth ; afterward lightly 
twist it upon itself. In making the twist, it seems to my own expe- 
rience that nothing is more necessary than that the bright polish of 
the foil should not be broken, while to avoid so breaking it requires 
only the exercise of a very little care. The twists are to be cut into 
pellets. 

Heavier foils — those which range from 20 to 120 — are commonly 
used, cut into little oblong squares, — a delicate strip being first cut 
from the leaf, and this subdivided into pieces of a size suited to the 
cavity to be filled. These heavy numbers are, however, confined 
mostly to use on the surface of a filling the bulk of which has been 
made by the lighter foils, or are otherwise employed for filling the 
root canals, — which see. 

Adhesive foil exposed to the atmosphere loses always more or 
less of its quality, this being a result of surface-moisture and dust- 
To restore the adhesiveness, it is the practice to anneal it, doing this 
either by laying it upon a heated plate, or by passing it through 
the flame of a spirit-lamp. The amount of heat to which foil is 
to be subjected will be found to vary considerably. A satis- 
factory test is found in the touch. My own plan is to pass the 
twist through the flame, and then touch to it a finger: if it sticks, it 
is to be considered sufficiently annealed ; if it does not stick, greater 
heat is required. A practice with many is to heat every twist to a 






LOCAL TREATMENT OF DENTAL CARIES. 337 

cherry-red ; and while such a rule may be found generally appli- 
cable, many lots of foil will be met with to which the treatment 
would be ruinous. A rule, however, to be observed in every case is 
not to burn the gold or heat it to an extent which destroys its soft- 
ness. A foil that is not made adhesive by a heat which varies from 
that which shall simply dry it up to that which exhibits the red, can 
never be made so by any such means ; it is faulty. 

It is not, however, to be understood that adhesive foil always 
requires annealing at the hands of the operator. Many makes are 
so perfect in this respect as received from the manufacturers, that it 
is only necessary to keep the books in a strictly dry place, and 
inclosed, when not being used, in the envelopes which accompany 
them. 

Placing foil in the rays of the sun, transmitted through glass, as 
an ordinary window, is one of the most satisfactory ways of anneal- 
ing. In cool weather I seldom employ artificial heat, finding the 
sunshine to answer every purpose. 

The instruments with which adhesive gold is worked are, as be- 
fore mentioned, serrated. In the production of such instruments, 
the most accomplished skill has exerted itself, both in the way of 
devising forms and in manufacturing. Instruments when too deeply 
serrated cut the gold, when too smooth they fail to assist the natural 
adhesiveness by addition of the quality of interdigitation. Atten- 
tion, however, is to be directed to the fact that operators of repute 
deny the necessity for serrations, and even, indeed, the desirability of 
using instruments so prepared, believing that adhesive foil is to be 
worked with better results by smooth-faced pluggers. 

To afford the reader all advantage which may be gained without 
actual manipulative trial, cuts are inserted representing the instru- 
ments of serrated character most in esteem by the experienced 
dentists of the country. It is to be found, perhaps, that in the use 
of these, as with the use of the various numbers of foil, familiarity 
constitutes the best recommendation. 

Fig. 110 exhibits perfectly the features of a set of pluggers, com- 
prising fifty-nine instruments, designed by William H. Atkinson, 
M.D., of New York City, and known by his name. Although 
intended to be used with the mallet, — a process yet to be described, 
— these instruments are found adapted to hand - pressure also. 
Lately, however, this set, long among the most celebrated, has 
been renounced by the designer, in a preference for smooth-faced 
pluggers. Much reputation still attaches to them with the best 

22 



338 



ORAL DISEASES AND SURGERY. 



practitioners. A too great depth in the serrations is an ob- 
jection that has been urged. A set of these instruments, 

Pig. 110. — The Atkinson Pluggers. 

• ••■=■ * * * @ h n n n - * * ^ ^ 



(((nidi 



Ull 



I I I I I II I 

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 



tiff 



ft P 



I (I (I 






irf 



\i((iij(\ a a j 



1 1 i 

22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 



n ri d n * 

A 



49 50 51 52 53 54 55 56 57 58 59 



LOCAL TREATMENT OF DENTAL CARIES. 339 
Fig. 111. — Burnishers. 




consisting of twenty-four pieces, selected from the full com- 
plement, is found to answer the purposes of most operators. 
Accompanying these pluggers is a set of burnishers of designs 
corresponding with requirements. Fig. Ill exhibits these bur- 
nishers. 

A set of pluggers, composed of sixteen pieces, designed by 
C. R. Butler, M.D., is represented in Fig. 112. These are in 
great favor with a wide circle of operators. The serrations, 
as seen in the cuts, are very fine. 

Fig. 112. — The Butler Pattern. 




2 3 4 5 



10 11 12 13 U 15 16 



340 



ORAL DISEASES AND SURGERY. 



Fig 113. — The Varney Pattern. 



f 



f t 



f f f 




n* 



\ 

5 



Still another set having individuality and reputa- 
tion is known as the Yarney pluggers, being the design 
of an operator of experience and recognized position. 
The serrations of these, like those of the Butler instru- 
ments, are very fine and very close. The set com- 
prises thirteen pieces. Fig. 113 represents these instru- 
ments. 

Another set, and which is the last that space will 
permit to be represented, is shown in Fig. 114. These 
are known as the Abbott pattern. Like the others, they 
have many admirers. The forms of these instruments 
will certainly not soon be surpassed. It would scarcely 
seem possible that an indication could present in shape 
or situation of a cavity that some one or other of these 
points would not reach. 

Other pluggers, well known and widely used, are 
sets known as Jack's, Ellis's, Goodwillie's, Forbes's, 
Darby's, and Head's. It is well, when visiting dental 
depots, to examine the many pronounced improvements 
constantly being issued, and to purchase accordingly. 

A set of instruments, which experience is thought to 
demonstrate as being full and complete for the purposes 
of filling teeth, is made up of the following pieces. 
These constitute a case recommended to the class of the 
Philadelphia Dental College by the Professor of Opera- 
tive Dentistry in that institution. 



LOCAL TREATMENT OF DENTAL CARIES. 341 



• I 



Fig. 114. — The Abbott Pattern. 

• • 





u i ii n i 

7 \] Vi n n 




12 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 

u \ j t I i ' I ' ' ' I J i i I ? 




19 20 21 22 23 24 




25 26 27 28 29 

Operating Case 



7 Head's excavators, 4, 7, 12, 17, 18, 20, 21. 

1 Palmer's nerve instruments, each Nos. 2 and 3. 
1 " " " No. 5. 

1 " " " No. 15. 
4 auger drills, two No. 3, 8, and 6. 

2 retaining-point drills, Nos. 1 and 2. 

8 wheel burs, Nos. 1, 3, 5, 7, 12, 15, 18, 9. 
7 round burs, Nos. 1 , 2, 3, 4, 7, 9, 12. 

1 cone head, odd No. 6. 

1 Goodwillie's excavator, No. 32. 

2j 5 2 dozen standard excavator hatchets, Nos. 16, 15, 14, 12, 10, 9, 50, 

47, 99, 81, 82, 85, 86. 
2 T \ dozen standard excavator hoes, Nos. 27, 28, 91, 75, 78, 79, 80, 57, 

59, 60. 
2 T \ dozen standard excavator scoops, Nos. 65, 66, 67, 68. 
7 £-inch f. c. pluggers N. Y., Nos. 127, 128, 101, 1, 4, 9, 99. 



49, 

58, 



342 ORAL DISEASES AND SURGERY. 

£ dozen S. S. W.'s small scalers, Nos. 1 and 8. 

5 i-inch f. c. burnishers, S. S. W.'s, 8, 6, 2 ; Darby's, 31 and 32. 

4 i-inch f. c. pluggers ; Ellis's, 10, 11, 12, and Darby's, No. 3. 

1 universal porte polisher. 

1 box corundum points. 

1 long handle wood magnifying mouth-mirror. 

1 Cogswell rubber-dam holder. 

1 J-inch f. c. rubber-dam punch. 

1 glass syringe, silver-plated mountings, with one curved pipe. 

1 J-inch f. c. plugger, bayonet-shape, no number. 

2 £-inch f. c. scalers, K. L. Stellwagen's pattern. 
1 f-inch bayonet-shape condenser. 

1 octagon handle plain steel small scaler, No. 5. 

1 set of six Jack's chisels, single-bladed, heavy handle. 

1 lead mallet in gas-pipe, nickel-plated. 

£ dozen five-sided drills, three-faced. 

1 set of ten mallet-pluggers. Nos. 1, 3, 4, 5, 6, 7, 8, 9 of the set of mallet- 

pluggers for sponge gold, No. 2 of Ellis's pluggers, and Atkinson's 

No. 32. 
£ dozen Eroid's separating files, Nos. 00 and 8, cut three sides. 
8 Murphy's files, Nos. 12, 20, 14, 33, 40, 41, 42, 19. 

3 « " Nos. 54, 99, 100. 

2 » " No. 81, E. and L. 

2 Scotch stones. 

1 box each pumice and polishing putty. 

J dozen square handle probes, one foil-carrier and plugger combined. 

1 abscess lancet. 

1 student's large morocco case. 

3 trays and instruments fitted. 

Fillings of adhesive gold are made either by hand-pressure or by 
the use of a mallet. Where the latter means is employed, experi- 
ence certainly demonstrates the necessity for shallower serrations in 
the instruments. Mallet filling consists simply in condensing the 
gold by repeated taps from a hammer made of wood, lead, tin, or 
steel, applied to the head of the plugger. To employ the mallet, an 
assistant is commonly deemed necessary, although not by any means 
an indispensable adjunct, the operator being quite able to manipu- 
late both plugger and mallet. Fig. 115 represents the size of mallets 
ordinarily used. No. 1 is made of metal, — lead, preferably ; No. 2 
is made Of lignum-vitae. 

Provided with some selection of the serrated pluggers, the opera- 
tion of fixing and packing adhesive gold may very well be practiced 
to its appreciation by employing the perfectly clean surface of a metal 
dollar, either silver or gold being used, as may be most convenient. 



LOCAL TREATMENT OF DENTAL CARIES. 



343 



First, that a hold maybe secured, the operator makes a series of 
cross-scratches over any portion of the surface. Taking up now 
with the serrated point a pellet of gold which has been prepared, it 

Fig. 115. — Plugging Mallets. 





is laid upon the scratches, and by a very few manipulative touches is 
solidly attached to the coin. The building up of a cone to any de- 
sired height is simply a repetition of these attachments. Appre- 
ciating thus the principle upon which a plug of adhesive gold is to 
be constructed, the practice may now be extended to simple crown 
cavities in teeth. 

To fill a simple crown cavity with adhesive gold, the operator 
(after the adoption of such means as shall insure him to the end of 
the operation against the inroad of saliva) takes up a piece of metal 
of such size as being packed solidly in the bottom of the cavity shall 
give it fixedness ; upon this first, piece after piece is to be at- 
tached, precisely as in the case of the coin. If the mallet is used, 
each second or third layer is to be condensed with it, although it is 
a habit with many operators to mallet every pellet ; a plan only 
permissible where the shallowest serrations are used, such frequent 
blows, where the instruments are at all deeply cut, quickly destroy- 
ing the integrity of the plug, as may very well be understood. 

Another mode of fixing the first piece of foil in such a cavity is 
to make at some convenient spot what is called a retaining point : 



344 ORAL DISEASES AND SURGERY. 

this is simply a slight undercut or slot: this first piece being worked 
into this slot, the remainder of the filling is attached to it. 

A much more convenient and certainly more expeditious way of 
filling such a cavity is found in wedging into it the gold prepared 
as cylinders, plates, or the cut rope. When no more can possibly 
be thus introduced, it may be hand-worked or malleted into solidity; 
foil, worked after the adhesive manner, being now attached wherever 
a place can be made for it: thus building up the required face. 

As another study in the use of adhesive foil, reference may be 
had to the cavities seen upon the grinding faces of molar teeth, Fig. 
78, running over into the lateral surface. With the cavity prepared 
as described, the operator will commence by fixing in either ex- 
tremity a pellet of gold, this being solidly malleted into place; 
upon this, pellet after pellet is attached, until the irregular, sulcus- 
like place is filled. 

We pass now to the proximal cavities — exhibited in the same 
figure — in the anterior teeth. Taking, as an example, the incisor 
tooth : the operation may be commenced with a pellet of gold 
carefully and delicately worked into an undercut, the remainder of 
the plug, as before directed, being attached to this. A plan, how- 
ever, which is exceedingly easy and convenient consists in first laying 
a plate, precisely as suggested in the use of unadhesive foil, against 
the neck- wall of the cavity; this is to be of such size that when 
consolidated into place its relation with the boundaries of the cavity 
makes it self-supporting. Against and into this wall of gold the 
adhesive pellets are to be worked with such serrated instruments as 
are found most convenient to apply. A third plan of filling such 
cavities consists in rolling into balls three suitable-sized twists of 
adhesive foil. Taking up the first ball, it is carried to the neck-wall 
and there partially condensed. The second ball is now placed iu 
that part of the cavity which adjoins the cutting edge; the third ball 
is wedged between the first and the second, and the mass is now 
condensed by the serrated pluggers against the labial wall. Having 
thus a support of gold immovably fixed by its relations with the 
neck and base of the cavity, the pellets are taken up piece by piece 
and worked into it until the cavity is full. 

Still another plan, practiced, after a little experience, with all satis- 
faction, consists in taking a single ball, prepared as just described, 
and, after carrying it into place against the neck-wall, holding it in 
position by means of any convenient instrument until it is condensed 
and a sufficient addition is made to render the mass self-supporting. 



LOCAL TREATMENT OF DENTAL CARIES. 345 

Yet another plan is found in the employment of a matrix. This 
may be extemporized out of almost anything". A very simple mode 
consists in casting- first a ligature of heavy silk well waxed about 
the neck of the tooth. Between the teeth — being of a width which 
shall cover in about one-fourth of the neck aspect of the cavity — a 
piece of soft silver is now thrust and wedged into place by a slip of 
soft wood. Into the cavity thus formed the initial of the plug is 
placed. A temporary matrix of this nature is also provided, as has 
been before suggested, by the introduction between the teeth of a 
lath-shaped instrument, the initial gold being by such means sup- 
ported until condensed and fixed. 

Heavy foils, even as high as No. 120, are used by some operators 
in filling the front teeth : it being claimed for gold so prepared that 
from being rolled instead of beaten it is rendered softer and more 
adhesive. Such gold, after being cut into delicate strips, is attached 
across the surface of the cavity, retaining points being first prepared 
and filled. 

Cavities in the bicuspid teeth, proximal surfaces, are filled accord- 
ing as they may have been prepared. Where the Y-cut has thrown 
the cavity into an upward outlook, — that is, has given it more 
or less the aspect of a common crown cavity, — no special sug- 
gestions are required to be added to directions already understood. 
In the contour-fillings, however, each case will possess its own 
peculiar indications. In preparing a bicuspid tooth for such a con- 
tour-filling it will be remembered that the cavity is cut from the 
grinding face : the tooth being, as it were, scooped out. This 
necessarily makes an open, free cavity, which will require some special 
means of support for the first piece of gold introduced. To obtain 
this support, it will be found convenient to take advantage of the 
undercut, such point of fixedness being secured at any convenient 
spot about the base of the cavity. A first piece being by this means 
fixed, the remainder of the plug is built upon it, the gold in mass 
becoming finally self-supporting as the cavity is packed. The use 
of a matrix is here found most conducive to convenience and suc- 
cess. 

A second means of filling such cavities, and one which will be 
found easier of accomplishment by the inexperienced, consists in pre- 
paring a series of plates or mats. After making a slight retaining 
undercut around the parietes of the cavity, a first plate is laid 
against the neck surface of the cavity and loosely condensed into 
place. A second and third are next placed against the lateral walls, 



346 ORAL DISEASES AND SURGERY. 

these also being loosely pressed into the undercuts. A fourth, fifth, 
and sixth, as required, are now wedged into the centre, each wedge, 
as will be seen, tending more and more to consolidate and fix the 
first layers. Securing thus fixedness for the gold, the whole may 
be carefully hand-worked or malleted solidly against the bottom ; 
the upper part of the cavity (exposed by the condensation) is filled 
by working adhesive pellets into the anchored portion of the plug, 
precisely as is built up the filling first described. 

In filling the lower teeth, it is common for the operator to be 
behind his patient, standing at such elevation as shall enable him to 
lean over the head or shoulder. Such a position is found to add 
immensely to convenience in manipulating. Another posture, prac- 
ticed by many, is to stand at the side, precisely as in operating upon 
the upper teeth, — a position that is found to answer a very good 
purpose where the cavities to be operated upon occupy the buccal 
face of the teeth, but which certainly cannot be compared for con- 
venience to the first position for crown or proximal cavities. In 
manipulating upon a cavity in any part of the mouth, advantage is 
of course to be taken of the various movements permitted by the 
operating-chair or head-rest. 

Building up with gold the entire lost crown of a tooth is an opera- 
tion frequently practiced by expert workers with adhesive gold. 
Such operations, however, are too often to be viewed rather as 
exhibitions of nice smithery than as proper and judicious surgical per- 
formances, it being exceptional that the root built upon does not 
rebel against the treatment pursued. To practice operations of such 
a class, the gold receives its fixedness either by anchorage in the 
pulp canal, or by gold screws roughened to attach and hold the 
metal worked into and about them. A plan that may be adopted, 
is to ream out the root precisely as for the accommodation of the 
tube of gold so frequently employed for the reception of artificial 
crowns, as in the process of pivoting. (See Pivot Teeth.) Into the 
canal, so prepared, is inserted the screw, which, it will be under- 
stood, has close relation with it near the apex only. The screw is 
now built solidly into the canal, furnishing a support for the crown, 
which the operator builds upon and about it. 

In the case of molar teeth, the practice has been pursued of drill- 
ing several holes into the circumference of the surface to be built 
upon, making these act the part of slots for the fixing of bases of 
gold, or the introduction of supporting screws. Mack's retaining- 



LOCAL TREATMENT OF DENTAL CARIES. 347 

screws, together with the instruments designed for their insertion, 
will be found highly self-commending in this direction. These screws, 
made of gold, are of delicate workmanship, and may be fixed into a 
tooth at any point, with entire facility, by the use of the drills and 
slotted carriers, which accompany. 

Concerning contour-fillings, the fact is not to be overlooked that 
such manner of restoring the lost parts of teeth is commended by 

Tig. 116. — Automatic Plttgger. 




most expert and experienced operators. And in this volume it is 
only meant to qualify an indorsement, as the manipulations are so 
frequently practiced by those who seem to consider only the me- 
chanical aspect of their cases. Objections to grinding surface gained 



348 



ORAL DISEASES AXD SURGERY. 



could certainly apply only where ill — necessarily accruing from the 
particular mode of operating — counterbalanced the good. 

The working of the sponge form of gold and of the prepared foil- 
block is conducted on the same principle and with the same form 
of instruments as employed with the adhesive foil. 

Apparatuses for use in filling teeth, designed for the saving of 
time, labor, and fatigue, are from time to time introduced to the 
notice of the busy operator. Automatic pluggers, as they are 
termed, are highly esteemed by many. Fig. 116 represents a 
form of such instrument, together with the mode of handling it. 
Of agents of this character, several modifications are found in the 
market, and, as each seems possessed of some special virtue, the 
mean of difference is perhaps not very great. The name automatic 
mallet seems quite as appropriate for these instruments, as the 
object is the combination of the mallet-blow with the plugger. The 
blow is the result of ingeniously arranged spring-work, and may be 
repeated with as much frequency as the fingers of the operator can 
with convenience manipulate. Directions for the working of these 
various machines are found to accompany the cases in which they 
are furnished. 

An instrument known as Bon will's electro-magnetic mallet is ex- 



Fig. 117. — Electro-aTagxetic Mallet (Hale Size). 

K B * s . 




hibited in Fig. 117. This is a most ingenious piece of mechanism, 
and in the hands of the inventor is remarked to work with a certaintv 



LOCAL TREATMENT OF DENTAL CARIES. 349 

and accuracy which would seem to be its all-sufficient recommenda- 
tion. It is composed, as is seen by referring to the diagram, of a 
horse-shoe magnet (H) with a frame attached, which supports the 
mallet or armature, and at the opposite end the cylinder or tube, open 
on one side for the thumb to rest on the plugger, which passes through 
it. J, the spring which secures the plugger from passing too far 
either way in the tube. 0, the black rubber key which, when pressed 
up by the right thumb while holding the instrument in hand, forces 
the lever up and breaks the circuit permanently. C, the platina points 
where the current is broken at the binding-post (P), and on the lever 
pressing thereon, which is controlled by the slide upon which rests the 
right index-finger. This is for the temporary breaking of the current. 
P, binding-posts for flexible wires, one coming from the battery (N), 
and the other from clock-work (M). S, screw for adjusting the 
hard-rubber head which strikes upon the head of the plugger. S', 
screws for holding the points or pinions which attach the armature 
or mallet to the frame. S /r , screws with hard-rubber heads, to 
keep the armature from coming in direct contact with the iron core 
of the helix or magnet, and which are adjustable to a hair's breadth. 
A, the conical spring which sustains the mallet and causes it to 
be thrown back from the helix or magnet. It is adjusted by the 
screw (I), upon which it rests, with binding screw for same. B, 
the bobbin or automatic feeder, upon which can be rolled a yard of 
gold tape, the ends being held together by pressure of hand plugger. 
By this, the operation can be carried on continuously where free 
action can be had. T is a deflector for directing the point of a 
curved plugger for posterior cavities in the second molars, which is 
screwed fast to the same spot where the automatic feeder now rests, 
first taking it off. 

The most important point to be kept in mind about this mallet is 
to see that the screws (S r/ ) are just far enough through the armature 
to keep it from coming in direct contact, at any part of the surface 
of the mallet, with the iron cores running through the magnets, and 
still not so far through as to raise the mallet beyond a very trifle 
from the cores. As nearly as can come without touching. 

This is necessary for two reasons: First, if allowed to touch the 
cores of the magnets, the latter would become permanently magnet- 
ized, and would not let the mallet fly back for its stroke; second, 
by thus finely adjusting the mallet the greatest power is obtained, 
as the magnet becomes stronger and the mallet gains in rapidity 
and sharpness of stroke in exact ratio as it approaches the magnet, 



350 ORAL DISEASES AND SURGERY. 

and inversely becomes weaker as it recedes. Hence the screws (S /r ) 
must be so finely set as to prevent any contact of the mallet with 
the cores. The same may be said of S. It must be set to allow 
the hard-rubber head to move the plugger-point about the one-fiftieth 
of an inch. If adjusted to strike when one-eighth of an inch away 
from the magnet, it would lose the best — sharpest and strongest — 
part of the blow. Besides, the shorter distance the plugger travels, 
the less rebound to the body of the instrument and the greater gain 
to the patient in comfort, as well as solidifying the gold far more 
surely. In these screws lies the whole secret of success, according 
to the statement of the inventor. 

The screws (S') must be just tight enough not to bind the pinions 
of the mallet, and a drop of oil placed on the pinions only, occasion- 
ally, the only part about the whole instrument which must be oiled. 
The screw (I) which regulates the conical spring (A) supporting the 
mallet, is made adjustable with the binding nut, so that when filling 
the upper teeth, the weight of the mallet is enough to take it away 
from the magnet; but when filling the lower teeth, the spring (A) 
must be made strong enough to throw the mallet up against the 
screw above, regulating the distance or width of stroke. 

Where a heavy stroke is wanted in regular succession for some 
time, let the mallet have longer play; if soft blows, then diminish 
the distance. Where the distance is great, the armature cannot fly 
back and forth so rapidly ; only where the distance between two points 
is less will the mallet run the faster. Take a pendulum for illus- 
tration. The mallet should run fast enough to strike three blows 
while the plugger-point rests at each touch upon the gold. 

To prevent any undue waste of material, the hard-rubber key (0), 
which is controlled by the right thumb, should be pressed down, 
when there is occasion to work at hand pressure or something else. 
This breaks the circuit at the post (P), and when no circuit there is 
no exhaustion of battery. The same key (0) is automatically 
pushed back again, when the instrument is taken into the hand for 
use, as soon as the second joint of the right index-finger comes in con- 
tact with the opposite end of the key. The slide, upon which the right 
index-finger rests, breaks the current temporarily, by drawing it 
backward, allowing no stroke of the mallet at the time, and enabling 
the operator to take up the foil on the point of the plugger, and at the 
same time prevents any exhaustion of the battery. 

This instrument is operated by three Bunsen cells, charged with 
dilute sulphuric acid and bichromate of potash, — the cups requiring 



LOCAL TREATMENT OF DENTAL CARIES. 351 

to be filled once a week. M , the' clock-work for breaking the cur- 
rent automatically, runs one hour from the winding. In some of 
the instruments furnished by the inventor, this clock-work arrange- 
ment is replaced by simpler means. 



From the consideration of the introduction of the filling, we may 
now pass to the processes of finishing. These consist in condensing 
the surface thoroughly, in filing the plug into such shape and rela- 
tion as shall accord with requirements, and in giving it a jewelly 
polish. 

To accomplish these ends, the operator will need files, conden- 
sers, burnishers, pumice- and rotten-stone, rouge, strips of tape or 
wash-leather, pieces of wood, etc. ; that is to say, he will find useful 
any means which shall conduce to the required ends. As condensing 
instruments are concerned, they find representation in the pluggers 
with the serrations filed off. Much pressure, however, being brought 
oftentimes to bear upon such instruments, especially where the mallet 
is not used, the manufacturer in preparing them considers such 

Fig. 118. — Finishing Files. 




"Sfito 



^ . Y\^ 




requirements, and by so much enlarges the size of the shank over 
that of the pluggers. 

Files used in finishing are prepared in the greatest possible 
variety. The separating files, figured on a foregoing page, are indis- 



352 



ORAL DISEASES AND SURGERY. 



pensable for use on the front teeth. Fig. 118 represents forms of files 
that are found useful in almost every position. Fig. 119 exhibits files 
prepared in the bur form. These latter have application in the 
cutting down of crown plugs, and accomplish their work with a 
nicety and finish which seem to prove them perfect. Fig. 119 
shows also the handle of these instruments. These bur files, when 



Fig. 119. — Bur and Wheel Files. 







worked by the pneumatic or the lathe engine, are revolved with a 
velocity which enables them quickly to cut into shape the hardest- 
made plug, Dr. Bonwill claiming for his instrument a rotatory 



Fig. 120. — Set of Burnishers. 





power of four thousand to the minute. Worked by hand, however, 
these files quickly enough accomplish the work, and will prove in 



LOCAL TREATMENT OF DENTAL CARIES. 353 

such manner of use sufficiently satisfactory to the majority of prac- 
titioners who may use them. The manner of employing the various 
forms of files does not merit space for description, as it is a matter 
self-suggestive. 

Burnishing instruments will also be found of many patterns, the 
designs corresponding with requirements. Fig. 120 represents a set 
of these instruments which will be recognized by the experienced to 

Fig. 121. — Porte Polishers. 




comprise all the forms for which there is real necessity. Indeed, it 
would be quite possible to do without Nos. 1, 3, 5, and T : such a 
set costing, however, not over six dollars, the outlay for the whole 
would soon be found covered by the extra convenience. No bur- 
nishing instrument except that made from the very finest of steel 
is worth possessing. The use of the burnisher is both to condense 
and to polish the face of a filling. It is to be used in connection 
with the file, the filling being alternately filed and planished. 

Among other instruments found convenient, if not absolutely 
necessary, in the process of finishing, are porte polishers. Fig. 121 
represents a set of three. These carriers enable the operator to fix 
splints of wood, upon which he carries pumice- or rotten-stone, at 
any angle found convenient in working. The use of pumice-stone 
so applied represents the finest file, and is found of the highest im- 
port in securing a proper surface. A porte polisher of satisfactory 
yet inexpensive character is made by soldering together at right 
angles two tubes of silver or of tin of a size fitted to support a handle 
of wood and the splint. As a porte polisher, the pneumatic engine 
of Green seems to possess an advantage in what might be termed 
a reciprocal motion belonging to its mechanism. Not only does it 

23 



3 54 ORAL DISEASES AND SURGERY. 

revolve a body, but with equal facility drives it forward and back- 

" A cavity being filled with gold, it is felt to be a necessity to secure 
a surface of sufficient polish to resist the absorption of moisture 
before the removal of the napkin. This is done with the bur- 
nisher, a polish being at once taken, provided the gold has been 
solidly packed ; should a polish not be taken, then the operator 
is to go over the surface with a condenser, using either hand- 
pressure or the mallet. These manipulations of burnishing and 
condensing in alternation are to be repeated until the protectmg 

polish is secured. , 

The condensation of a filling is most conveniently effected through 
the aid of the mallet. The blows struck are at first to be very 
light, that thus unequal consolidation may be avoided ; it is best 
that at the commencement the instrument be directed about the 
circumference of the plug, the centre being gradually approached, the 
operator thus avoiding the drawing of the metal from the panetes- 
an important matter, as a very little experience will not fa.l to-shuw 
Having made such condensation of the surface, it is to be followed 
bv the burnisher or file, as shall seem indicated. It is always most 
important to avoid any overhanging of the walls by the gold ; his 
implies that a cavity should not be overfull. In crown fillmgs, this 
is a not uncommon fault. Where it is seen to exist, the bur hie 
may follow the burnisher. The face of a crown-plug should, when 
finished, be concave, corresponding with the aspect of the surface 
of which it forms a part. In securing such relation of parts the 
fillino- will always be found of more resisting surface if the cutting 
down has been done little by little, the burnisher being used 
very frequently as such cutting is effected. The final finish is 
K iven to a plug by the alternate use of the burnisher and the 
parte polisher, pumice- or Arkansas-stone being first used, and after 
this rotten-stone, crocus, or rouge; through such means the sur- 
face of a plug may be made as solid and polished as the molten 

""in 'finishing proximal fillings, wherever situated, it is felt to be 
desirable to give such plane to the surface as shall render it self- 
cleansing : this is most simply secured by making the metal corre- 
spond with the V-shaped cuts which have been advised : in the 
anterior teeth this is effected with all convenience by the use of 
the convex separating file as seen in Fig. 79. In the posterior teeth 
the operator will select from his case any files that are suitable and 



LOCAL TREATMENT OF DENTAL CARIES. 355 

easy of manipulation. Among the forms exhibited in Fig. 85 he 
may find himself suited. Cuts made in the V-shape are not entirely 
void of objection. It is not unfrequently the case that the particles 
of food, instead of passing quickly and cleanly over the surface, tend 
to pack in the interspace, thus being a source of discomfort to the 
patient, and at times provocative of a species of chronic ulitis. 
Such jamming is, however, oftentimes the result of the manner of 
filing, — a matter which soon comes to be corrected by a growing 
experience. In place of such packing of the ingesta being an objec- 
tion, it is with force argued by many that it is a positive good, com- 
pelling, through the discomfort induced, that attention to absolute 
cleanliness which is the object of the space. 

A proximal plug filed into the required relation, the polishing and 
finishing follow as with the crown-plug. Strips of holly wood, 
corundum tape, or wash-leather, wet and dipped into pulverized 
pumice, or twists of ordinary candle-wick used in a similar manner, 
will be found valuable adjuncts, affording a fineness of surface which 
cannot, without a much greater amount of labor, be had through 
the instrumental^ of partly-worn files. These strips are used 
simply by drawing them back and forth over the surface to be 
smoothed. Rotten-stone and rouge or the peroxide of tin are em- 
ployed upon the strips for the finish. 

In finishing contour-fillings, such regard as may be had is to be 
given to self-cleansing properties. Such plugs are filed into a shape 
corresponding with the natural contour of the tooth. That they 
may render any prolonged service, they must have such solidity as 
shall enable them to bear the strain endured by the original parts. 
The process of finishing is the same in principle as that employed 
in the cases just described. In shaping the articulating face it 
is necessary, however, that special regard be given to the contact 
of the opposing tooth or teeth, — a matter which frequently demands 
much time and care. In shaping contour-fillings, it is generally 
found convenient to use delicate slabs of the Arkansas or similar 
stone, rubbing thus from the gold every scratch or indentation. 
Finish, it is to be remembered, is the expression of stability and force 
in a contour-filling, as it is only a solid and reliable filling that 
is capable of taking a fine finish. 

A reaction from the plane to the contour form of filling, evidently 
just now setting in, will not unlikely carry such manner of operating 
into extremes. Contour-fillings certainly exhibit mechanical skill 
on the part of an operator; and, besides, such plugs have an 



356 ORAL DISEASES AND SURGERY. 

advantage in the lost surface they restore. If solidly made, and if 
the joints are perfect, it would be true that as the matter of cleanli- 
ness is concerned, teeth thus restored would be in no worse condition 
than in their original state. A query may, however, very justly 
arise as to whether surfaces may not be made to the improve- 
ment of parts of certain condition as naturally existing. The 
experience and judgment of the author favor the inclined plane. 
Like many other excellent things, such plane is, however, fre- 
quentty carried to excess : the attainment of the highest good 
is to secure a surface sufficiently inclined to forward anything strik- 
ing against it, while at the same time preserving all the cutting 
face possible. Contour-filling, as is recognized, leaves no dentine 
exposed. 

In concluding the subject of filling the decayed crowns of teeth 
with gold, the student is reminded that the principles which are 
to govern him are, " That all difficult cavities are to be converted 
into those of simple form ; and that space is always to be secured, 
either by the file, chisel, or pressure, which shall give the required 
room for manipulation." 

The File as a prophylactic and curative agent. 

Having upon former pages described the use of the file from the 
strictly mechanical standpoint, we pass now to the consideration of 
the instrument as a prophylactic and curative means. 

In the process of preparing proximal cavities for filling, it has 
been seen that in very many cases — indeed, in the great majority — 
the dentine of the teeth has been exposed, and that afterward no 
steps have been taken for its protection. This absence of care arises 
from the experience that such dentine left to itself does not tend to 
decay, but that when the operation of filing has been accomplished 
with judgment and the proper delicacy, it seems in quite as resistive 
a condition as before being denuded. 

Acting on the premises of such an experience, it is to be com- 
mended not only that conditions of incipient caries be filed away, 
but also that in irregular dentures the irregularities which invite 
disease be treated — in prophylaxis — in like manner. Of all the 
various operations performed upon the teeth, none, certainly, demands 
more experience than this we are now studying ; or if experience is 
to be replaced, it may only be by a judgment which possesses the 
fullest recognition of the requirements. 



LOCAL TREATMENT OF DENIAL CARIES. 857 

It is to be borne in mind as a cardinal principle that, in prophy- 
laxis, dentine is never to be uncovered except the surface exposed 
maybe made self-cleansing; hence it is at once seen that certain 
positions of decay preclude this treatment; cavities, for example, 
occupying sulci upou the grinding faces of the molars. 

A second principle which is to possess its weight with the operator 
lies in the premise that the file is not to be used upon teeth the 
conformation and relation of which will not insure continuance of 
the position in which the operation leaves them. This second might 
be considered but an iteration of the first premise if it were not so 
well known that filed teeth, unless wedged, tend to change position. 
Hence the judicious use of the file implies not only a present, but 
the future. In Fig. 122 an illustration is given of what is meant. 

Observing the bicuspid aud approx- 

T^tp 1 22 
imating teeth in this diagram, it is 

seen that between the first molar and 

the second bicuspis the file has been 

passed directly through to the gum, 

the space being the same behind as 

in front, and at the necks as at the 

cutting edges ; this is, as seen, a 

free and open space. Referring now 

to the cuspo-bicuspis relation, it is 

shown that these teeth, which have 

been filed in a precisely similar manner, have fallen together, and so 

fallen as clearly to exhibit the impossibility of keeping them cleansed 

unless by a care that very few persons are found to give to the 

teeth. Teeth so filed are cut only to their injury, unless, indeed, it 

might be that by the act of cutting such response was excited from 

the pulp as to eventuate in a resistive consolidation of the structure, 

— a result that it would scarcely be wise to anticipate, being certainly 

possible, but scarcely probable. 

Eburnification or vitrifaction, the process by which exposed and 
irritated dentine becomes self-protective, has been described on a 
preceding page. An operator, before resting anticipations of the cure 
of superficial caries on the file, is to appreciate well the responsive 
efforts with which the manipulations are likely to meet. 

Teeth of soft character are perhaps never found so tolerant of the 
file as are those of more solid structure, and when cut not unfre- 
quently give way as by a process of invisible ulceration, just, indeed, 
as caries in bone, while so commonly cured through the relief 




358 ORAL DISEASES AND SURGERY. 

afforded from operative means, will be seen at times and under 
adverse systemic influences to have had the little force which existed 
destroyed by the operation. This is the case with the tooth where 
the pulp life, instead of reacting, succumbs to the irritation. 

Appreciating these conditions influencing the use of the file, our 
study may lead us to an observation of examples illustrative in the 
direction. 

As a first of such examples, attention may be directed to surfaces 
of contact between teeth of the two dentures. A permanent tooth 
manifesting expressions of proximal change and being adjoined by 
a tooth of the first set, which tooth exhibits itself in the relation to 
be a cause of offense, may, if such first tooth is not too sensitive, 
find relief by filing directed exclusively to the latter organ. The 
use of the file is here and there oftentimes made available as the 
approximal relations of the six-year molar and second deciduous 
are concerned, or as are related the temporary cnspis and a perma- 
nent bicuspis, or, still again, as the permanent superior incisores 
centrales and milk laterales are seen to be sources of mutual 
injury. Milk teeth, it is to be recognized, may not, however, 
always be filed with impunity: in very irritable temperaments 
spasms might very readily be found to result from such an 
operation. 

Referring now to the six superior anterior teeth of the permanent 
set, it is to be recognized that caries attacking the proximal surfaces 
is not an infrequent condition, being excited, in part at least, as has 
been suggested, not only by the lodgment of detritus, but by a motion 
attendant on the masticatory act, which motion abrades or cracks 
the enamel of these surfaces. 

To discover incipient disease of the proximal faces of teeth in 
the very earliest stage is a matter of no difficulty. A waxed thread 
passed into the interspaces exhibiting roughness of the surface, or 
a sharp excavator demonstrating the existence of a process of soften- 
ing, readily enough gives cognizance of the affection. Teeth so 
conditioned, if reasonably hard and of such shape as to permit 
of self-sustaining separation, may be cut with the prospect of a 
permanent cure. If, on the contrary, the structure be soft, and if 
the relation be such that continued separation is not to be secured, 
then it must of necessity prove the better practice to depend, at a 
period somewhat later, on separation by means of wedges and the 
clearing out and filling of a cavity that may ensue. In the interim, 



LOCAL TREATMENT OF DENTAL CARIES. 359 

however, the disease is to be held much in abeyance by means of 
waxed floss silk passed frequently, by polishing with soft powders 
used as for dressing fillings, and by attention to every condition 
which may be recognized as an agent of offense. 

In filing away incipient caries, inclined surfaces are always to be 
aimed at. Such surfaces secured and maintained, the parts from 
necessity are made self-cleansing ; the act of mastication itself is 
made a cleansing act. Especially is this so where the denuded sur- 
face has been burnished and polished with that care which is as 
indispensable as the plane itself. 

To prevent filed teeth from falling together, it is requisite to 
secure at some position surfaces of abutment; such a surface, when 
possible, is to be maintained at the necks of the teeth. This abutting 
surface is, however, in itself an ill, — but it is the smallest part of a 
common ill combated. When the absence of abutment of the teeth 
at the neck does not allow of the sustaining points being here 
secured, it may be proper first to press the teeth asunder by means 
of a wedge of wood as directed in the chapter on fillings, and, having 
thus the enamel in front intact, cut, by means of a safe-edged separ- 
ating file of convex face, a V-space the base of which looks into the 
oral cavity. The wedge removed, and the teeth coming together, 
it is plainly seen that only the enamel-covered edges left in front may 
impinge. The diagram, Fig. 78, right side, exhibits surfaces rendered 
self-cleansing. 

The objection to the employment of the file, prevalent among 
the community, has arisen from the fact that the instrument has 
been used with so little judgment : perversions, both pathological 
and artistic, have been witnessed as more commonly the result than 
good; hence in reasonable data has this prejudice had its origin. 
Such ill, however, resides no more in the instrument of itself than 
does discord in the keys of the piano, and nothing is required but 
the intelligent touch to disabuse the minds of the people of such 
prejudice. 

That sensibility of dentine and irritation of the dental pulp are 
frequently witnessed in connection with filing teeth, is a fact too 
common to be denied. Indeed, many sets of teeth have been 
rendered permanently useless from such results ; but here error 
in judgment has influenced the operation. Another objection urged 
against filing has been thought to lie in chronic ulitis engendered 
by the pressure of ingesta. Teeth filed as exhibited in diagram, 



360 ORAL DISEASES AND SURGERY. 

Fig. 122, could but result in such conditions ; but the fault here, as 
in the example above, lies with the operator.* 

Under the head of Odontalgia we may now consider conditions 
which complicate the subject of filling teeth ; understanding which 
complications, the matter of root-filling intelligently follows. 

* A work has lately been issued entitled "Prevention of Decay of the 
Teeth," written by Bobert Arthur, M.D., of Baltimore, in which the subject 
of the file as a prophylactic and curative agent is discussed at much length. 



CHAPTER XI V. 

THE TEETH AND THEIR DISEASES. 

ODONTALGIA. 

Under this common head we shall consider all the various pains 
in the teeth, however induced. The term comes from the two Greek 
roots, odous, a tooth, and algos, pain — odontalgia, toothache, or pain 
in a tooth. 

The causes of toothache may be classed under the following 
heads : 

1. Sensitive dentine. 

2. Direct or indirect exposure of the pulp to sources of irritation. 

3. A diseased state of the periodonteum. 

4. Confinement of pus and gas in the pulp cavity. 

5. Granules of osteo-dentine in the pulp. 

6. Sympathy. 

7. Recession and absorption of the gum and alveolus. 

1. Sensitive Dentine. — Some teeth, immediately on the breaking 
down of the enamel and the consequent exposure of the dentine, 
become exceedingly sensitive, or, in other words, exhibit themselves 
as peculiarly susceptible to the influences of irritating agents. This 
impressibility is attempted to be explained by the most dissimilar 
hypotheses, few subjects connected with the teeth having elicited 
more discussion and controversy.* 

* An observation of the pulps of certain teeth which have been exposed to 
irritation in cavities unopened as well as open will exhibit the existence of 
fungoid excrescences. Only very lately it has happened to the author to open 
several teeth which had been partly destroyed by caries, the pulp chamber, 
however, being intact; in two of these cases a magnifying glass of very 
ordinary power exhibited thread-like excrescences of most minute and fibrilla- 
like appearance, passing in clusters from the surface of that portion of the 
body of the pulp adjoining the cavity of decay. These excrescences were in 
each instance of a pearly-white color, and might well have been likened to 
bundles of the most delicate cobweb. It is suggested to the attention of the 
microscopist that it may be possible that such excrescences passing into the 

(361) 



362 ORAL DISEASES AND SURGERY. 

In teeth thus sensitive, the operation of excavation is occasionally 
found so painful as to be quite unbearable, and may only be accom- 
plished through the employment of means that shall lessen such 
sensibility- Even sweets taken into the mouth, or cold or hot 
drinks, or acids, the latter particularly, will occasionally provoke 
pain in such teeth. Instances quite numerous exist where such 
dentinal sensibility is continuous, the pain being of a dull annoying 
character existing quite independent of foreign agents of offense. 
In these latter cases the exciting cause must be looked for in some 
irritative condition existing in the oral fluids : these may be too 
acid or too alkaline. Tests, however, are here easily made with 
the aid of litmus or turmeric paper, and specific remedies accordingly 
may have immediate employment. 

As direct applications to teeth sensitive from the nature of their 
organization, medicinal obtunders in the greatest variety are sug- 
gested. Of these perhaps the most permanently effective is arsenic: 
this application, however, possesses an objection in ill results almost 
certain to accrue to the dental pulp which render the use of it en- 
tirely inadmissible ; it is, nevertheless, very frequently employed. 

Chloride of zinc is a favorite preparation, and where used imme- 
diately preparatory to excavating will be found commonly to answer 
most satisfactorily. In the employment of this agent, as in that of 
the arsenic, care is to be exercised that such impression be not pro- 
duced as shall unduly irritate the pulp The application of the 
chloride of zinc is variously made. A common mode is to take a 
deliquesced preparation, dropping it, when it may conveniently be 
done, from the point of an instrument into the cavity, which cavity 

tubular structure have been mistaken for nerve-fibrillae. Without qualifica- 
tion, however, the author believes that exception may be taken to the doctrine 
that nerves pass from the pulp into the tubuli. It scarcely seems to need the 
microscope to demonstrate the correctness of such an opinion. That fibrillae, 
however, may he found in teeth of loose structure, being intertubular, may 
readily be received as a fact, but their origin is to be sought in the enamel 
membrane and not in the pulp. One explanation at least of sensitive dentine 
would seem to be found in the relation of the dentinal circulation to the pulp 
through the medium of the halitus of the chamber; this finds (at times) 
demonstration in the marked relief so commonly gained through absorption 
from the cavity of all moisture, and the preservation of such dryness during 
the process of cutting. That entire dryness in a dental carious cavity is 
among the best antidotes to sensibility has come to have such common prac- 
tical recognition that a large class of the most experienced operators rely 
exclusively upon it. 



THE TEETH AND THE IB DISEASES. 363 

has been previously dried ; the parts being protected from any 
inroad of moisture by means of the napkin or dam. .Another mode 
consists in employing a pellet of cotton saturated with the zinc. Still 
another mode, and that preferred by the author, consists in using the 
crystals direct, a few of these being placed in a cavity and allowed 
there to deliquesce. 

The almost immediate result of zinc applied to a sensitive cavity 
is the production of sharp pain ; this, however, is commonly found 
to disappear in from one to two minutes, when, the sensibility having 
been obtunded by the action of the agent upon the superficies of the 
cavity, excavation may painlessly proceed to that extent of depth to 
which the salt has acted. Reapplications may be made as found 
necessary, although it is to be recognized that the fewer one can 
get along with the better for the subsequent health of the tooth. 

Chloride of zinc in full strength kills immediately the part to 
which it is applied; diluted, it is very apt to irritate only, increasing 
the very sensibility it is used to destroy. Where the pain attend- 
ant on the application of the zinc is objectionable to the patient, it 
may be in great part obtunded by a preliminary employment of the 
solution of sulphate of atropia. 

Another mode is found in mixing the two agents together in equal 
parts, and employing the combination. 

Agents having no ulterior ill influence, and which frequently 
render all required service, are found in such preparations as creasote, 
chloroform, an ethereal solution of the ter-chloride of gold, aconite, 
sulphate or acetate of morphia, chromic acid, atropia, nitrate of silver, 
glycerole of thymol used warm, etc. It is sometimes found that 
by sealing up in a cavity for one or two hours either the sulphate 
of atropia or morphia, the former preferably, — but always to be used 
with great care, — excavation may be accomplished with entire 
absence of pain. Cauterizing the cavity with a point of the nitrate 
of silver frequently answers the same end. A mixture of equal parts 
of tincture of aconite and a saturated solution of iodine is highly 
recommended as an excellent cauterant and obtunder. The value of 
any or all of these agents is not, however, to be overestimated, as 
a very little experience will be sure to make evident. What will be 
found to answer most satisfactorily in one case may have little effect 
in another. 

A means of overcoming the difficulty w T hich is perhaps more reliable 
than the employment of obtunding agents, consists in using very 
sharp excavators and by rapid motion making deep cuts sweep- 



364 ORAL DISEASES AND SURGERY. 

ing the circumference of the cavity ; in acid mouths, where the 
carious mass is mostly made up of semi-devitalized animal matter, 
such treatment will commonly prove so satisfactory that upon the 
removal of a superficial horny layer all sensibility will be found to 
have disappeared. The success of this manner of treatment does 
not, however, apply so happily in alkaline mouths or in the case of 
very hard teeth. Indeed, it may be said that in such dense teeth 
zinc alone is the only agent yet known which invites any special 
sense of reliance. 

Sensibility of dentine is also at times found to be dependent not 
on a strictly localized hyperesthesia, but on true inflammation. 
Here the indication is for precisely the treatment required for in- 
flammation in general. 

In directing treatment to a sensitive cavity, it is most necessary 
also to distinguish between the common sensibility and sensibility 
depending on exposure of the dental pulp. Attention, it will be 
recalled, was on a former page directed to cornuse of the pulp cavity, 
which in certain instances are found quite nearly to approach the 
surface. Such distinction, however, is generally easily enough made 
through the aid of an exploring instrument, — an excavator or 
nerve-plugger being used ; if at any point there is exposure of the 
pulp, the touch of the instrument cannot fail to distinguish it, as the 
pain induced by the contact would not be found to apply to other 
parts of the cavity. 

Another condition of similar import exists where the cavity of 
decay so nearly approaches the pulp chamber as to render each 
stroke of the instrument an agent of irritation. This condition is to be 
recognized in the depth of the common cavity, and in the tenderness 
being most associated with the deepest part. These cases require 
great delicacy in manipulation, as an inadvertent cut would most 
likely plunge into the substance of the pulp. 

Etherization, as a means to enable the operator to excavate a sen- 
sitive tooth, is not unfrequently resorted to. This certainly most 
effectually answers the purpose; and where a patient may be easily 
affected, as is so frequently the case, a few inhalations inducing in- 
sensibility, there would seem to be no objection to its employment. 
Anaesthesia need not, of course, be carried to any profound extent. 

The administration in hyper-sensitive cases of morphia sub- 
cutaneously, or preferably by the mouth, is a practice that the 
annoyed practitioner need not hesitate to adopt. To an adult a 
quarter of a grain may be given half an hour before commencing 



THE TEETH AND THEIR DISEASES. 365 

the excavation. Bromide of potassium answers also at times a 
very reliable purpose ; twenty-five grains may be administered. 
Syrup of lactucarium is another valuable agent ; it is to be prescribed 
in tablespoonful doses. All of these means affect the local by dimin- 
ishing the general sensibility. Local anaesthesia as induced by the 
ethereal spray is by some highly recommended, — the atomized fluid 
to be directed in continuous current upon the tooth until the excava- 
tion is completed ; risk to the pulp would seem, however, to be 
associated with the operation. 

Viewing sensitive dentine as a cause of odontalgia, the operator 
finds his most permanent means of cure in the introduction of a fill- 
ing into the cavity. Another means resorted to, as a temporary treat- 
ment, is the excavation and polishing of the surface. Still others, 
the cauterization, as above suggested, with the solid nitrate of silver, 
or the use of the various other agents mentioned. A method very 
satisfactory where the parts are very sensitive consists in introducing 
into the unexcavated cavity a filling of oxychloride of zinc. The sensi- 
tive grooves so often met with across the neck portion of the face of 
the teeth are frequently to be most happily treated by the occasional 
repetition of the polishing of the surface by means of a burnisher. 
Such means here is greatly to be preferred to the use of the zinc. 

2. Direct or Indirect Exposure of the Pulp to Sources of Irri- 
tation. — Reference to the anatomy and relations of the dental pulp 
exhibits it as a body composed of the most delicate connective tissue, 
in which ramify nerves, arteries, and veins. This body is lodged 
in a bony cavity, sufficient only in size for its comfortable accommo- 
dation, and for the halitus or fluid which surrounds it. Any undue 
congestion will therefore at once be perceived to result in a pressure, 
which, from the presence of nerve-matter, must cause acute pain. 
This appreciated, the pains resulting from an inflamed pulp must be 
admitted to be alike in general character. 

A pulp need not, as suggested in connection with applications 
employed to obtund sensitive dentine, be fairly exposed to be the 
subject of irritation. 

Cases not unfrequently occur where the plate or floor of a cavity 
is so thin and so altered in structure that it will yield or bend. 
In these instances the agencies of mastication may and do readily 
enough force this plate down upon the pulp. As a consequence of 
such pressure we have irritation, and, it may be, inflammation. 

Irritation of a pulp is much more apt, however, to be associated 



366 ORAL DISEASES AND SURGERY. 

with its exposure. Here everything entering into the cavity is a 
source of offense, and the lesion is always plainly enough discovera- 
ble; foreign particles coming in contact with such an exposed pulp 
give instant and perhaps excessive pain. This pain may quickly 
subside, or it may continue for hours or days ; in the latter case, 
inflammation will be found to have established itself. 

A free and open break into the pulp cavity is attended with much 
less pain in inflammation of the organ than a more limited exposure. 
In the first case, the swelling pulp has plenty of room, and conse- 
quently less pressure is exerted on the nerve-filaments. In the 
second, the protruding congested organ quickly becomes strangulated, 
and thus pain of the most acute and severe character is induced. 

The treatment of an exposed pulp is of a twofold character, — palli- 
ative and radical. The first consists in the employment of soothing 
and quieting applications, and is employed principally for the relief 
of children. The second implies the destruction of the pulp ; this 
being generally effected through the instrumentality of escharotic 
applications. To quiet an irritated pulp, a first attention is to be 
directed to the removal of every source of offense. If the fluids 
of the mouth be irritative, the character of the condition must be 
sought for and corrected. If foreign particles have found their 
way into the cavity of decay, they are to be carefully syringed away 
with warm water. Such attention may be all that is needed. If 
not, and the excitability continues, recourse should be had to sooth- 
ing applications : the tincture of hamamelis applied warm, or the 
oil of cloves, or creasote much diluted, or chloroform, aconite, and 
laudanum, in equal parts, will sometimes act very happily, particu- 
larly in such cases as depend upon excitation unattended with inflam- 
mation. Where evidence of congestion or vascular excitement of any 
grade exists, lead-water and laudanum will frequently act like magic. 
Persulphate of iron and tincture of iodine are found sometimes to 
act very happily in similar conditions, constringing the vessels, and 
thus breaking up, or aborting, as it w 7 ere, the congestion. In the 
odontalgia of first dentition, it is well that parents be provided with 
some order of general prescription. A very good one is as follows, to 
be applied by saturating a small piece of cotton and laying it loosely 
in the cavity: 

B. — Creasoti, gtt. vj ; 

Tincturae iodinii, 3j ; 

Liquoris plumbi subacetatis, 5j ; 

Chloroformi, 

Tincturse opii, aa 5ss. M. 



THE TEETH AND THEIR DISEASES. 367 

Such a prescription is suggested on the principle of Dewees' 
carminative, and is found most apt to meet, in some one of its 
ingredients, the single or various indications that may be present. 

In severe inflammation of the pulp, it may be necessary to con- 
join with the directly local the more indirect means of medication: 
blisters upon the nape of the neck will frequently result in speedy 
relief; hot pediluvia; saline cathartic medicines, as the sulphate or 
carbonate of magnesia; diaphoretics, as the spirits of Mindererus, 
or Dover's powder; or diuretics, as the nitre preparations. An in- 
flammation of the dental pulp, if not too far advanced, will almost 
invariably be broken up by the administration of from five to forty 
grains of bromide of potassium, the application of a mustard poultice 
to the back of the neck, and a hot foot-bath, continued from twenty 
minutes to half an hour, 

The atropise sulphas is also to be relied upon as an invaluable 
agent in soothing or obtunding the pain of an irritated pulp. If 
severe inflammation has not supervened, and if the trouble has been 
taken to rinse from the cavity any detritus of offense, the instances 
will be found few indeed where it will not afford almost immediate 
relief. 

R. — Atropiaa sulphatis, gr. v j ; 
Aquae destillataa, gj. M. 

To be marked " poison" for safety, and to be applied precisely as 
the immediately preceding combination. 

A cause of odontalgia from an irritated pulp frequently exists in 
the case of plugged teeth, from proximity to this organ of the mate- 
rial used in the filling. In these instances a constant irritation is 
kept up by thermal impressions induced by the presence of the metal. 
If inflammation supervenes, the pain, because of the perfectly in- 
closed condition of the pulp, becomes of the most acute and unbear- 
able character ; relief will generally be obtained by the removal of 
the filling ; or, if this should not succeed, the pulp may be treated as 
shortly to be described. Where several teeth are in a state of irri- 
tation from such a cause, and confusion of distinct location is thereby 
induced (as is not unfrequently witnessed), the affected teeth can be 
made clearly to designate themselves by holding cold water in the 
mouth ; or, what is even better, by touching each particular filling 
with some cold steel instrument. The increase in sensation will 
commonly be thus made very marked. 

The operator may frequently cure such teeth by introducing 



368 ORAL DISEASES AND SURGERY. 

between the filling and floor of the cavity some non-conducting sub- 
stance, — a piece of ordinary quill, a particle of asbestos, a layer of 
gutta-percha, a portion of the Hill stopping, or a cap of gold. 

Still another source of irritation to the dental pulp is found in 
the wearing down of the teeth. This is particularly observed in 
persons who use large quantities of tobacco, or in such as have the 
upper and lower teeth directly articulating. Happily, however, in 
the generality of such cases, nature antagonizes the external influ- 
ence by depositing, in quantities as needed, secondary or osteo-den- 
tine within the pulp cavity, at the same time contracting this organ, 
so that, in proportion as the tooth wears away on its cutting face, 
the pulp recedes, and casts out, as -its protection, this secondary 
material. It is a beautiful and wonderful process of offense and de- 
fense, and commands our admiration. 

In some cases, however, and these not a few, this reparative or 
protective power does not seem to exist; where this happens, the 
pulp, of course, soon becomes the subject of irritation. I have seen 
some of the severest cases of odontalgia result from such a cause. 
The only cure is found in the destruction of the pulp. To apply 
arsenical paste under such circumstances (see radical treatment of 
pulp), there being no cavity of decay, it will be sufficient to lay it 
in the cup-shaped depression commonly existing on the cutting faces 
of such teeth (the result of the more rapid wearing of the inner dental 
structure than of the outer enamel wall), keeping it in place with a 
covering of wax. When possible, however, it is much better, and 
more speedy practice, carefully to drill an opening into the pulp 
cavity, and with a delicate needle pick the arsenic directly into the 
pulp. The death of the organ secured, it is to be removed from its 
cavity by a barbed brooch, and its place supplied with gold. Another 
mode of devitalizing the pulp of such a tooth will be found described 
in connection with the setting of pivot-teeth (which see). 

Improper union of metals in the filling of a tooth is another not 
unfrequent source of irritation to the dental pulp. Tin foil is some- 
times placed in the bottom of a cavity, and the operation finished 
with gold. In many instances (depending not unlikely on lack of 
solidity in the overlying plug, thus admitting moisture) this combi- 
nation produces a galvanic action, which, if not removed, will quickly 
enough destroy the pulp. 

Still another source of irritation is the employment, in cavities 
more or less in proximity to the pulp, of the preparation described 
as tooth-bone : the chloride of zinc used in excess in the compound 



THE TEETH AND THEIR DISEASES. 369 

will not unfrequently, within a very few hours after its application, 
produce an inflammation in the parts almost, if not entirely, uncon- 
trollable. Few preparations require to be used with more judgment. 
A tooth so irritated is to have the filling removed, and perhaps it 
will always be found the best practice to finish the death of the pulp 
as speedily as possible. Asa reverse to this, it is to be recognized 
that the use of this material, as has been explained, will sometimes 
be provocative of just sufficient irritation to excite the secretion 
of secondary dentine, thus proving the best practice that could have 
been pursued. 

A pulp may give every evidence of being in an irritated condition 
where the osseous integrit}^ of the tooth is perfect, or seemingly so. 
Here the cause may be still strictly local, or it may be constitutional. 
Blows received by a tooth often result in such irritation. Atmos- 
pheric changes will sometimes account for the condition. Pieces of 
ice brought and retained in contact with teeth of loose structure are 
frequent sources of such trouble. Cracks in the enamel, induced 
from whatever cause, and permitting the impression of external 
influences upon the dentine, are other explanations. In a constitu- 
tional direction, rheumatism is, perhaps, the most frequent source ; 
after this, gout. Keflex or radiated irritability is a frequent manifes- 
tation. This is, perhaps, most observable in the hysterical female. 
In these cases no special practice may be directed. It is only neces- 
sary to discover the cause of offense, wherever and however situated, 
and, if possible, remove it. In the odontalgia of gout, dependence 
may be placed on the exhibition of colchicum ; twenty drops of the 
vinum colchici radicis, three or four times a day, according to the 
urgency of the symptoms, may be given. In rheumatism, I know 
of no better combination than the following. Its administration, 
in the plethoric, should be preceded by a free purging with a saline 
cathartic. 

R. — Potassii iodidi, gss ; 

Tincturse colchici radicis, jfss ; 

Extracti belladonna, gr. vj ; 

Tincturse guaiaci composites, 

Aquae cinnamomi, aa gvj. M. 

Sig. — To the adult give a tablespoonful three times a day in a little 
water ; if it act too freely on the bowels, add opium q. s. 

Functional derangements of the stomach might perhaps deserve 
special attention as reflex or radiated odontalgia is concerned. Any 

24 



370 ORAL DISEASES AND SURGERY. 

one who has ever observed the relationship existing between the 
pneutnogastric and the third nerve, as manifesting functional stom- 
achic derangement in the enlargement of the pupil of the eye, will be 
at no loss to associate the fifth and the ninth nerve. Pure neuralgia, 
as the term has common signification, is, I am satisfied, a very rare 
affection ; an aching nerve will generally be found to have some 
lesion outside of a so-esteemed idiopathic condition, and the lesion 
can generally be discovered by closely looking after it. (See Cause 
of Sympathy.) 

Passing now to the consideration of the same conditions as refer- 
ence is had to a tooth required to be filled, we will be impressed 
with the intelligence and observation which have enveloped the 
subject with the light of a common and reliable experience. 

We first consider the condition of a tooth with the pulp chamber 
nearly exposed, — a very thin lamina of dentine existing between the 
two cavities. A pulp in this state and relation has, as the result of 
its subjection to irritating influences, one of three sequelae. It may 
maintain, just as it normally exists, its integrity unaffected by the 
associations. Second, it may accept just that extent of stimulation 
which re-excites the formative capacity, increasing the distance be- 
tween it and external relations by a secretion consolidating the 
overlying dentinal structure, and not unlikely attaching a secondary 
deposit between itself and the original boundary of its cavity. 
Third, it may succumb to the irritation which its force may not be 
able to combat, inflammation, acute or chronic, supervening, and 
suppuration resulting. 

Of the probable results in all such cases, a reasonable experience 
enables the observing practitioner to form a fairly reliable estimate. 
To maintain that all pulps in such relation are to be saved is to 
maintain a very foolish fallacy. A dental pulp is a part of the 
organic life with which it is found related, and will be seen to have 
residing in it the impressions of the system at large. Thus, a first 
observation necessarily considers the state of health in the individual 
who may be the patient. As here shall be found equilibrium in 
excitability, with normal nutritional functions, or otherwise degen- 
erative tendencies, so will it be the experience that attempts to save 
dental pulps are responded to or defied. 

Founding the practice to be pursued in each particular case upon 
an experience which shall come of such observation, if indeed it 
be not already possessed by him whose judgment acts from the 



THE TEETH AND THEIR DISEASES. 371 

foundation of a knowledge of the principles governing all such 
matters, the practitioner determines either on destroying the pulp 
and removing it, or on an attempt to preserve it. This latter 
determination is always to have the benefit of any doubt which may 
exist in the mind of the operator, as it is never to be overlooked 
that a destroyed pulp signifies necessarily a tooth with a diminished 
vitality, which makes it a body more or less foreign to the parts 
with which it is in association. 

The destruction of a pulp decided on, the operation is to be 
accomplished as follows : Should irritability and pain be present, they 
are, if convenient and possible, to be first subdued by such means as 
were suggested on a previous page: quiet secured, and anaesthesia 
existing, by reason of the presence of the morphia, or, still better, 
the atropia. The operator uses, of what is known as nerve paste, 
a portion corresponding with the requirements of his case ; a 
piece larger than the ordinary pin-head being seldom needed. This 
paste is dropped gently into the deepest part of the cavity and over- 
laid with a pellet of cotton, which is made protective of external 
influences by means of a solution of gum sandarac, which may be 
dropped upon it from the point of an instrument after being placed 
in the cavity, or otherwise it may be slightly touched to the solution 
previous to being put in place. A very little experience will demon- 
strate that it is undesirable to have the cotton too fully saturated, — 
an objection that is sure to exist if some little care is not taken, the 
solution being absorbed eagerly. Formulae for nerve paste are 
variously given, but the author has found every reason to be satisfied 
with that suggested on page 144. In very irritable conditions it 
might be found, however, not inadvisable to substitute for the mor- 
phia the atropise sulphas. 

R. — Acidi arseniosi, 

Morphise acetatis vel atropise sulphatis, aa gr. x ; 

Creasoti, q. s. 
S. — A thick paste to be made. 

The length of time that arsenic should be allowed to remain in a 
tooth will be found to depend upon the structure of the organ and 
the amount of the material that has been used. A proper amount 
would be just that quantity necessary to accomplish the destruction 
of the pulp, and which in such destruction would find itself antagon- 
ized. As such a quantum might not, however, have accurate meas- 
urement, it is found desirable to consider rather the structure of the 



372 ORAL DISEASES AND SURGERY. 

tooth ; where this is found very solid and close, there may exist 
little objection to allowing the preparation to take care of itself. 
Where, however, such structure is loose, with organic matter in 
excess, — a condition made satisfactorily evident by a few cuts with 
an excavator, — the effect of an application is to be watched with a 
judgment which, perhaps, comes only of experience. A period 
which shall approximate a rule, however, in which arsenic may be left 
in the adult tooth, is fifteen hours; although nothing is more common 
than to allow it to remain for twenty-four. The danger in excess 
of time would seem to lie in the passage of the agent through the 
foramen and tubuli, affecting thus the periodonteum. 

That the action of an arsenical application on a pulp in a tooth of 
loose structure shall be as direct and speedy as possible, it would 
seem to be a desirable practice — where the touch is sufficiently deli- 
cate to accomplish it painlessly — freely to expose the organ before 
making the application. Such exposure effected, the paste may be 
at once pricked, by means of a very sharp-pointed broach, into the 
organ. By such an operation a pulp may be destroyed almost 
without pain, particularly if atropia be previously used as an ob- 
tunder, and may be removed from its cavity within a period of time 
not exceeding fifteen minutes. 

Recognition of the death of a pulp is found in the absence of the 
previously-existing sensibility, as made manifest by the touch of the 
exploring instrument. (See Filling Roots.) 

3. A Diseased State of the Periodonteum. (See Periodontitis 
and Alveolar Abscess.) 

4. Confinement of Pus and Gas in the Pulp Cavity. — When 
the dental pulp dies, decomposition is likely to follow. As the 
result of such lesion we have two sequences : either the decomposed 
matter is gradually absorbed into the dentinal tubuli, and thus dis- 
posed of, as made evident in the marked opacity of the tooth, or it 
becomes a source of great irritation and offense to the surrounding 
healthy structures. Periodontitis is very apt to be provoked, the 
evolution of gas forcing the matter unduly into, and in many cases 
entirely through, the foramen. If inflammation of the alveolo-dental 
membrane does not result, then the trouble induced becomes of the 
ordinary neuralgic character. The living nerve-filament at the fora- 
men, still more or less associated with its continuation ramifying in 
the dead pulp, takes on inflammation, and thus irritability not only of 
these special filaments results, but the whole trifacial tract is apt to 



THE TEETH AND THEIR DISEASES. 373 

sympathize. Some of the most severe and unbearable neuralgias I 
have ever treated, situated about the various parts of the head, have 
been quickly cured by discovering- and treating the cause in a confined 
dead pulp. I just now recall a marked example, — a patient of the 
late Dr. Elisha Townsend, — treated by me for that gentleman during 
the sickness which destroyed his valuable life. The patient was a 
professional man, and had been completely lost to all self-control, or 
reason, for a period of three days, from the effect of neuralgic pain 
running between the orbit and the dura mater of the anterior portion 
of the cranial cavity. In this case not the slightest complaint was 
made of any of the teeth. Examining the mouth, however, in the 
search for a cause, I discovered a half-carious and evidently dead 
lower bicuspid tooth, but with no connection between the cavity of 
decay and the pulp cavity. With a spear-shaped drill I effected this 
communication, and in a single instant the patient expressed himself 
as cured. Relieved of the pain, he fell into a sound sleep, which 
continued some fifteen hours ; the next morning he went about his 
duties as usual. 

Any portion of the head, throat, or associate parts supplied by 
the fifth nerve, or, indeed, by its related nerves, may be the seat of 
reflex trouble from a dead pulp. Thus we may have odonto-gas- 
tralgia, odonto-cephalalgia, odonto-cardialgia, etc. ; even sciatica has 
been cured by the extraction of a diseased tooth. 

The common treatment in all such cases is to remove the tooth, 
or otherwise, if it is desirable to save the organ, drill an opening 
into the pulp cavity. The relief experienced is generally almost 
instantaneous. 

A tooth containing a dead pulp is distinguished by its loss of 
translucency when compared with its fellows, or in an opacity, ex- 
hibited by reflecting upon it, by means of a hand-mirror, the rays 
of the sun. 

A case illustrative of practice in this direction finds example in 
a patient under the care of the author at the moment of writing 
this paragraph. Mrs. H., a lady of delicate organization, suffered 
for a whole week with severe pain situated in the alveolar region 
overlying the superior incisor teeth, — the teeth, however, seeming 
not at all implicated. In the beginning of the second week the 
lady first presented herself, directing attention to an elongation of 
the right central tooth, but which elongation, according to the 
statement of the mother, had always existed. Examination of the 
mouth exhibited not the slightest discoloration or inflammation 



374 ORAL DISEASES AND SURGERY. 

about the gums. The lateral incisor, however, was recognized 
to be very slightly loose, — this and the continuous pain being the 
only expressions of a pathological condition. Diagnosing the exist- 
ence of a dead pulp in this tooth, the chamber was entered by 
means of a spear drill applied to the palatine face ; on opening the 
cavity at least a teaspoonful of pus escaped into the mouth. A 
treatment pursued, which has so nearly eventuated in a cure that 
the patient will be dismissed on her next visit, is as follows : The 
quantity of pus demonstrating the existence of a reservoir outside 
the tooth, an incision was made through the gum at the apex of 
the root, exposing the bone. To this bone was next applied the 
point of a strong bistoury, which being pressed forward was felt to 
pass through a shell of bone and enter a cavity ; out of this cavity 
issued a second volume of pus. Examination of the cyst exhibited 
it as capable of accommodating all the fluid that had escaped, while, 
furthermore, absorption was seen to be progressing towards the 
right naris, into which, without doubt, sooner or later, the abscess 
would have discharged itself. The cavity, after being washed out, 
was injected with the ordinary officinal tincture of iodine, a tent of 
cotton being inserted to keep the opening in the soft parts patulous. 
On the third day the pulp canal of the tooth was filled with gold 
to its apex, great care being taken that no portion of the metal 
should be thrust through the foramen, which foramen, without doubt, 
was enlarged. Up to the present hour — two weeks having passed — 
the cyst has been daily injected with the iodine solution ; and the 
cavity has been daily growing smaller, until it is now so nearly 
obliterated that it may be left to take care of itself. 

The inflammation in this particular case was decidedly of a cold 
or chronic character. Had it been acute, the tooth would have been 
found too painful to fill with so short a period intervening between the 
time of attack and operation. One sinus, however, is always enough 
in an alveolar abscess; if it exists in the gum there can be no objection 
to filling the tooth so soon as the sensibility of the organ may admit. 

The splitting of teeth from expansion of gas confined in a pulp 
cavity seems a matter of record too authentic to be doubted. A case 
having peculiar interest in such direction, published by Dr. J. H. 
M'Quillen, is to be found on the pages of the Dental Cosmos, 
vol. xiii. 

5. Granules of Osteo-dentine in the Pulp. — In rare cases there 
is found to exist an irritability of the dental pulp which exhausts 



THE TEETH AND THEIR DISEASES. 375 

itself in the formation of isolated granules of semi-bonelike char- 
acter, which obtain lodgment in some portion of the organ, and 
become, in turn, the source of great offense to the parts, result- 
ing indeed frequently in an odontalgia than which there are few 
severer forms. To diagnose this condition is an exceedingly diffi- 
cult matter, and it can, perhaps, be best done by exclusion. The 
teeth in these cases present every appearance of the highest health : 
no discoloration, no soreness on pressure, and not unfrequently being 
without the slightest local pain ; this manifestation being situated 
in some distant part, as the ear, the eye, the scalp, etc. Whether, 
however, the pain may be localized or diffused, it is always ex- 
pressed by the patient as being entirely unbearable, and is commonly 
more or less paroxysmal in character, thus being mistaken for idio- 
pathic neuralgia, and frequently so treated. A case illustrative just 
comes to my mind. During a late session of the University of Penn- 
sylvania, a student in the medical department applied to me, suf- 
fering from neuralgia, so severe as to have entirely incapacitated 
him for study for a period of some three weeks. During this time 
he had tried all the ordinary remedies which had suggested them- 
selves, without finding the slightest relief. The pain varied between 
the tuberosity of the superior maxilla and the ear. The teeth, about 
the tuberosity, were as sound and as healthy-looking as any I have 
ever seen; there was apparently no local lesion; while, on the other 
hand, the physique of the gentleman was not at all of the neuralgic 
type. I was perfectly at sea with the case, until, after a day or 
two, there came to my mind an instance of innodular calcification of 
the dental pulp I had once seen, where the patient had suffered in 
about a like manner. Now, I was not prepared positively to affirm 
that here was a second case of calcification; but so well satisfied 
was I of the existence of such a condition that I requested and 
obtained the consent of the gentleman that I should pass an 
exploratory drill into the pulp cavity of the wisdom tooth. The 
result was the finding of the pulp filled with granules — granules 
of secondary dentine, as they are technically termed. The extrac- 
tion of the tooth was followed by the immediate cessation of all 
pain, and the patient was able to go from my office direct to 
lectures. 

A marked case, where the lesion gives direct local manifestation, 
the pain being seated directly in the affected tooth, exists in the 
person of a professional friend. The gentleman may be said to be 
affected with a diathesis in this direction. More beautiful teeth 



376 ORAL DISEASES AND SURGERY. 

than he possesses, or, rather, did possess, I have never seen ; and 
yet, one by one, they take on this condition, exciting such madden- 
ing pain that, regardless of everything, he flies to extraction for 
relief. In this way, within the past few years, he has lost all his 
upper teeth. 

The treatment of this form of odontalgia consists in drilling into 
the body of the affected tooth, and securing thus a cavity of reten- 
tion ; apply the arsenious paste as has been directed. There are, 
however, cases in which, under these circumstances, it seems im- 
possible to effect the destruction of the organ. Here there is nothing 
to be done but to extract the tooth or teeth. 

The subject of the changes which may take place in the dental 
pulp, being the result either of age or other circumstances, com- 
mands, necessarily, the attention of the surgeon. "Much as physi- 
ologists differ with regard to the precise method of dentification," says 
Mr. R. T. Hulme, M.R.C.S., in an admirable paper " On the Calci- 
fication of the Dental Pulp," "yet all are agreed that it takes place 
through the agency of the pulp, and that, commencing on the apex 
and external surface of the formative organ, it then proceeds inward 
until the tooth acquires its prescribed form and size, and the dentine 
has attained its normal thickness. When this is accomplished, the 
formation of the tooth is completed, and the same arrest of growth 
takes place as occurs in every other part of the body at the adult 
period of life. If the person enjoys good health, and the tooth 
remains free from injury or disease, it may continue for some years 
without any appreciable alteration, in either the osseous tissues 
which enter into its formation, or in the pulp itself. Sooner or later, 
however, as years go on, a change takes place in the character of 
the nutritive process throughout the body. The proportion which 
the fluids bore to the solids in early or middle life is diminished, 
nutrition is accomplished more slowly, and the composition of the 
various tissues undergoes a marked alteration. There is a general 
induration of the parts, and a tendency to the deposition of ossific 
matter: ligament is converted into cartilage, cartilage into bone, 
the coats of the blood-vessels are often impregnated with calcareous 
matter, and the cartilage of the ribs becomes ossified. If we turn 
our attention to the teeth, or, more correctly speaking, to their pulps, 
we shall find that they also are liable to a similar alteration of 
structure. When a section is made through an old tooth, apart 
from the changes which may be noticed in the color and transparency 
of certain portions of the original dentine, the pulp cavity will be 



THE TEETH AND THEIR, DISEASES. 



377 



Pig. 123. Fig. 124. 




seen to have been greatly encroached upon, and the entire mass of 

the tooth increased in thickness. The extent to 

which this filling-up of the pulp cavity can take 

place is shown in the accompanying drawings. 

Fig. 123 represents a section of a fully-developed 

molar in early life, when the tooth has attained 

its normal amount of growth; while Fig. 124 

represents a similar section of a molar tooth 

taken from an elderly person, and in which the 

pulp cavity has become diminished to the extent of fully one-half of 

its original dimensions. This change in the cavity of the tooth can 

only have taken place through the agency of the pulp, which, after 

a period of repose, must have returned to its original function of 

calcification, and have added fresh layers of dentine to the inner 

surface of the tooth. 

"'The teeth,' says Wedl, 'are distinguished at different ages by 
a diminution of the pulp cavity, an increase of thickness in the 
cementum, and a lessening of that of the enamel, and of the trans- 
parency of the three dental substances ; by the edges and angles 
becoming blunted, and the surface assuming a yellow tinge, etc. 
These distinctions are most striking in the teeth of old men. In 
the pulp of teeth in this condition will be noticed a considerable 
diminution in the quantity of blood, the color of that tissue often 
passing into a brownish yellow, from the quantity of pigment de- 
posited in it. Earthy salts, assuming the outward form of the 
botryoidal corpuscles met with in the pineal gland, occur on the 
inner surface of the pulp cavity and of the dental canal, and also 
deposited in groups in the substance of the pulp. An increased 
number of layers of cementum will be observed, though these are 
often concealed by the opaque, brownish-yellow color of the inter- 
corpuscular substance. In thin sections, the dentine, sometimes 
throughout, sometimes only in isolated spots, appears less trans- 
parent than natural, and the dentinal tubes become less distinct, 
and occasionally disappear in the dark-gray or brownish-yellow 
substance. These partial opacities of the dentine are manifested, 
even to the naked eye, by a speckled appearance. The enamel 
presents dark, reddish-brown spots, and, as well as the dentine, 
appears to have lost some of its elasticity, and to have become more 
brittle.'" 

Teeth subjected to sources of local irritation are frequently — indeed, 
it is rather to be said, are commonly — found responsive in the way 



378 



ORAL DISEASES AND SURGERY. 



Fig. 125. 



of self-attempting deposits. This subject has been discussed in con- 
nection with filling and filing teeth. In Fig. 125 
is exhibited a tooth which, as may be seen, has 
been worn into a groove at the neck ; in the pulp 
cavity, antagonizing the groove, is seen a deposit 
of secondary dentine. 

The re-formative efforts of the dental pulp dif- 
fer from conditions as shown in the diagrams to 
the complete conversion of its substance into a 
species of dentine, so that it is often found, on 
cutting open a tooth long subjected to irritating 
influences, that the cavity commonly existing is 
occupied by solid matter. 

A form of secondary dentine occasionally met 
with is shown in Fig. 126. This diagram repre- 
sents a specimen met with by Mr. S. J. Salter, 
and by him presented to the attention of the 
Pathological Society of London. In this case, 
as is seen, the mass is attached to the chamber 
wall of the tooth. 

" The tooth, as mentioned in Mr. Hulme's 
paper, was a central incisor which had been 
extracted from a woman on account of severe 
neuralgic pains, obviously connected with one of 
the central incisors of the upper jaw. The pain was described as 
of a gnawing character, abiding, but not constantly severe ; frequently 
amounting to a mere consciousness of the presence of the tooth, and 
at other times sharp and darting. In the former condition it was 
confined to the region of the tooth ; in the latter, it flashed up the 
side of the face, and through all the branches of the superior max- 
illary division of the fifth nerve of that side. Sudden pressure or 
a tap upon the tooth, or a marked change of temperature, produced 
a considerable augmentation of pain. The tooth itself was sound, 
to all external appearance ; it was somewhat elongated beyond its 
fellow, and was very slightly loose. The gum surrounding it was 
red at the edge, and a little swollen. When the tooth was removed, 
no exostosis was discovered on it; and, with the exception of some 
small patches of half-organized lymph, it appeared quite healthy. 

"Upon making a vertical section of the tooth from side to side, 
an oval pear-like excrescence of dentine was found growing from 
the side of the pulp cavity, so as to encroach much upon it, and 




THE TEETH AND THEIR DISEASES. 



379 



occupying for a short space more than half its diameter. It was of 
an oval form, its long axis corresponding to that of the tooth ; in 
color less opaque, and yellower than the neighboring tissue. 



Pig. 126. 



Fig. 127. 





••' The structure was of that irregular character which has been 
previously described as occurring in secondary dentine, which has 
arisen from the wearing away of some part of the tooth's surface. 
The removal of the tooth was accompanied with a violent paroxysm 
of neuralgic agony, but was followed by a total cessation of pain, 
and the cure was permanent " 

Masses of dentine — nodular dentine, as it has been named by Mr. 
Salter — occupying positions in the substance of the pulp, are to be 
met with as among the causes of odonto-neuralgia, as alluded to on a 
former page. These nodules may be single or multiform ; the author 
has in his possession specimens in which at least a dozen are to be 
found in the same pulp. These nodules differ markedly in form. 
Dr. J. F. Flagg, whose curiosity has prompted him to the preserva- 
tion of a large number of specimens, makes an interesting classi- 
fication. 

Taking advantage of a cut at command (Fig. 127), a specimen is 
shown from the collection of Mr. Hulme, and which is thus described 
by that gentleman : 

"Examination of the Tooth. — The decay extended to the pulp 
cavity, and the median third of the crown was more or less affected 
by caries. The tooth was then broken open and the pulp examined. 
It was of a pinkish color, and somewhat more vascular than usual. 
On endeavoring to withdraw the pulp from the cavity, at the part 



380 ORAL DISEASES AXD SURGERY. 

which was directly under the carious portion there was found a solid 
lump of osseous matter as large as a canary-seed, and something 
less than a grain in weight ; it was not adherent to any part of the 
inner wall of the tooth. On examining the remainder of the pulp 
beneath the microscope after the addition of a solution of caustic 
soda, it was seen to be thickly crowded with rounded masses of den- 
tine, but more opaque and of a different character to the dentine 
globules of Czermac. The drawing represents the appearance pre- 
sented by this portion of the pulp."' 

Xo form of odonto-neuralgia is more severe and persistent than 
this arising from pulp calcification. In this direction it has happened 
to the author since his connection with the University Hospital to 
see among the clinic patients quite a number of cases. The diagno- 
sis is perhaps always a matter of difficulty, and at times only satis- 
factorily to be settled by the extraction of teeth presenting more or 
less evidence of complication. (See Xeuralgia ) 

6. Sympathy. — Sympathetic toothache is most frequently found 
to be associated with teeth having a common period of eruption. 
Thus, if attention is called to an aching bicuspis, and examination 
discovers it to be in healthy condition, we will commonly find the 
primary lesion in either of the three fellow-teeth. If it is the first 
or third molar, or any particular tooth, that may seem to be aching, 
the real seat of pain may be found in the associate organs. This is 
the first and most common relation of sympathy. Other and in- 
direct causes exist in various directions, the most constant of such 
associations being, first, with the ear, second, with the uterus. 

That odonto-otalgia, cephalalgia, gastralgia, — indeed, any reflex or 
radiated pain having origin in the teeth, but expressing its manifes- 
tation in distant organs, and vice versa, — may exist, is at once to be 
appreciated in a recollection of anatomical associations ; instances 
abundant are on record illustrative of such relationship. Thus, as 
an example, allusion may be made to a case reported by J. L. Sues- 
serott, M.D., of Chambersburg. "The patient. Mr. J. G., an old man 
seventy years of age, applied to me,'' says Dr. S., "with the hope 
of being relieved of an intensely painful tic douloureux through the 
extraction of two or three fragments of roots of the superior incisor 
teeth, all the other teeth and roots of the upper jaw having been 
long before extracted." 

The suffering of the patient at the time of this first visit is de- 
scribed as of an extreme character, "a breath of air, the slamming 



THE TEETH AND THEIR DISEASES. 381 

of a door, or even an allusion to his disease, being sufficient to pro- 
duce a violent paroxysm. The irritation, although reflected, as it 
afterward proved to be, appeared confined principally to the superior 
and middle branches of the par trigeminum of the left side. This 
suffering had been so intense and long-continued that there was 
considerable swelling and tenderness upon pressure along the course 
of all the ramifications of the fifth pair. 

" Feelingthe case," continues the description, " to be a desperate one, 
although not suspecting the causa morbi, I determined on an active 
and energetic course of treatment. Directing my efforts to the 
removal of the existing irritation, and I might also say inflammation, 
I established an issue on the back of the neck, which, together with 
blisters to his temples, produced a considerable amount of counter- 
irritation. The external use of aconitine, and the internal adminis- 
tration of the citrate of iron and quinine in full doses, produced a 
marked alleviation ; but just at the time when hope was the brightest, 
another severe paroxj^sm would fill us with disappointment, and 
almost compel us to declare that there is no virtue in medicine. 

"A period of two weeks having been uselessly expended, together 
with no small amount of medicine and patience, the patient, as I 
was dressing his issue, happened to remark that ' his stomach was 
not in fault, for that he could digest without discomfort pieces of 
meat as large as he could swallow. 1 Those who have anxiously 
watched over an interesting and difficult case can enter into my 
feelings of gratulation, for, like Archimedes, I felt I might exclaim, 
Eureka ! Remembering the old maxim, tolle causam, cessat effectus, 
I directed my efforts to the improvement of the patient's manner of 
mastication and to the directing of a proper character of food, with 
the result of a speedy cure of his trouble." 

As an example of reflection in an opposite direction, a case may 
be cited from an interesting and valuable paper read by Julius 
Chesebrough, D.D.S., before the American Dental Association. 

"I have seen," says this gentleman, "a case wherein a fine- 
formed young woman suffered for a year after the birth of her child 
with pain in her teeth, alternately with that of the uterus. This 
case was one that had perplexed the physician in charge, and was 
presented to the medical society for advice. Being called on, and a 
statement of the case made to me, I at once suggested that the 
uterine derangement came from the teeth, and that these organs were 
the only morbid ones. There was some doubt expressed as to this 
being a correct diagnosis of the case, for she had no toothache before 



382 ORAL DISEASES AND SURGERY. 

her labor, and the pain in her teeth was since that event. Suggest- 
ing that examination be made of the teeth, a visit was paid the 
patient, with the result of finding decay in the four wisdom-teeth. 
Three of these were extracted without giving much pain, but while 
extracting the fourth — the left superior — it seemed as if the woman 
was contracting within herself, and suffered intensely from uterine 
pain. After half an hour, however, her pain ceased, and she was 
entirely free." 

A case even more directly the opposite of the first example is 
mentioned in this same paper, in which a patient suffering from 
continual pain in the stomach was only cured upon the accidental 
treatment of a carious tooth, — the pain in the stomach ceasing imme- 
diately upon the application of arsenical paste to an exposed pulp. 
A second time the same patient is reported as presenting himself, — 
the pain, which was of similar character and location as in the first 
instance, finding again immediate cure in the treatment of a second 
diseased tooth. In neither instance was pain noticed in the teeth. 

Of the various viscera, cases illustrative might be given of odon- 
talgic association, while pains outside the splanchnic cavities, as in 
the hip-joint, etc., have found relief not unfrequently only in attention 
directed to the teeth. In the chapter on neuralgia the reader will 
find the subject abundantly illustrated. 

To understand the subject of the radiation or reflection of pain, 
consideration is to be given to the anatomical associations of the 
nervous system. This considers the cerebro-spinal and ganglionic 
systems, and refers the reader to his text-books on anatomy and 
physiology. 

T. Recession and Absorption of the Gum and Alveolus. — When, 
for any reason, the gum falls below the enamel cap, the periodon- 
teum and cementum become exposed to various sources of irrita- 
tion. The odontalgia thus provoked is seldom, however, acute 
or severe in its character, but dull and annoying. The practice in 
these cases is generally most unsatisfactory, resulting, sooner or 
later, in the necessity for extraction. If the recession is associated 
with acute conditions or with the presence of agents of offense, 
treatment directed to meet the indications may result very well ; 
but commonly such recession is slow and chronic, and admits of no 
remedy. Medicaments to neutralize or correct irritative conditions 
in the oral fluid are sometimes demanded, and answer a very good 
end. Of such neutralizing agents, acids or antacids are employed, 



THE TEETH AND THEIR DISEASES. 383 

according to the indications yielded to the test papers. I myself 
generally use lime-water in the one direction, and very dilute citric 
acid in the other. 

A treatment for absorption of the alveolus suggested by Dr. 
Riggs, of New York, consists in scraping the absorbing bone, pre- 
cisely as is done in osseous caries. This is to be accomplished 
without difficulty by introducing between the neck of the tooth and 
gum the common lathe-shaped excavator, which, upon reaching the 
alveolus, is made to cut away the surface surrounding the tooth. 
Dr. Riggs recommends instruments especially prepared for the 
purpose, but any instrument which is capable of meeting the indica- 
tion answers the purpose of the suggestion. Such an operation 
has, in theory, much to commend it ; in practice, however, the 
author has not found himself able to get from it the benefit claimed 
to have accrued in the practice of the gentleman devising it. 

A character of recession of the gums from about the necks of the 
teeth, or, to express it better, a condition in which the teeth are 
raised in their sockets, and where a cure is impossible, is found as 
the result of a growing density in the structure, in which the 
equilibrium of circulation between these organs and surrounding 
parts becomes so deranged that they are as foreign bodies, and 
the recession really implies a filling-up of the alveoli by an osseous 
deposit with the object of their removal. In these cases the teeth 
will seldom be seen affected by caries, being dense to an extent 
which is cognizable to the naked eye. 

Recession arising from the employment of non-soluble dentifrices 
is frequently to be met with. Such condition is to be recognized from 
the history of the case, from the presence of particles of the sub- 
stance of offense, and from the disease seeming to implicate the gum 
alone. Such cases have their cure in withdrawal from use of the 
injurious agent, in the free syringing of the part with a medicated 
water, — stimulation being required, — and in effecting the contraction 
of the turgid gums by free bleeding secured through occasional scari- 
fication. 



CHAPTER XV. 

THE TEETH AND THEIR DISEASES. 

FILLING THE PULP CHAMBEK AND CANALS. 

The pulp of a tooth dead, and the intention being to save the 
organ, appreciation is now to be had of the means tending to such 
end. It is, indeed, within the memory of the present generation 
when a dead pulp was considered synonymous with the loss of a 
tooth. Now, however, it has come, happily, to be recognized that 
such attendant loss is the exception,— observation eliciting the fact 
that the almost universally associated destructive sequelae depended 
on the presence of the putrid mass in the cavity rather than on the 
fact of death of the pulp. 

With such understanding, the first step in the treatment of the 
pulp chamber and canal is seen to consist in the most thorough 
cleansing of them from substance which has become foreign. 

To remove a dead pulp, the operator commences by creating an 
opening into the chamber, or in enlarging to convenient size one 
that may already exist; this accomplished, it is not unfrequently 
the case that the pulp may be caught and lifted away with a pair 
of delicate finger-forceps. A more common mode of procedure, 
however, consists in the employment of a barbed broach ; this instru- 
ment being passed into the canal, and, when rotated, catching and 
twisting into its teeth the pulp, its withdrawal brings with it neces- 
sarily the structure. Fig. 128 represents a barbed broach, a variety 
of blades being shown adapted to a common handle. 

In attempting to remove a pulp entirely dead, it is occasionally 
found that considerable pain attends the operation. This pain Will 
be found to depend on the manipulations. A broach thrust directly 
upon a dead pulp will carry necessarily the impression to the living 
structure still in relation at the foramen of the canal. A proper 
plan is to enlarge the opening to such extent as shall allow the 
introduction of the instrument between the wall of the canal and the 
pulp. Delicately insinuated in this manner, and the rotation com- 
(384) 



Fig. 128. 



THE TEETH AND THEIR DISEASES. 



Fig. 129. — Nerve Extractors. 



385 



- — Drawn Temper. 



-Spring Temp 




' 



12 3 4 5 

mencing only when the instrument has reached the bottom 
of the canal, a pulp may commonly be removed without a 
particle of discomfort. 

In teeth having more than one root, it is generally found 
necessary first to remove the pulp of the chamber proper. 
This may be effected through the use of a common ex- 
cavator, simply cutting it away ; the continuations, occupy- 
ing the canals, are now to be removed, as described, by the 
use of the broach. 

An indication following immediately the removal of a 
dead pulp consists in such sealing of the emptied chamber 
and canals as shall prevent occupancy by foreign matter, 
whether from within or from without. This embraces the 
processes of preparation and filling, — a subject to which 
attention may now be directed. 

Taking as a first example a tooth from which, after the 
arsenical application, the devitalized pulp has just been 
removed, the operator is to consider that the surface of 
separation at the foramen of the tooth cures itself either 
by the process of what might be called an immediate 
cicatrization, or by granulative effort, attended with more 
or less degeneration of plasma and discharge. Could 
assurance be entertained of the first result, then no better 
practice might be pursued than the immediate introduc- 
tion of a permanent filling. As this may not, however, 
V * whh^ e ^ ne case > what is termed a test stopping is to be used. 



tractor 
holder 



25 



386 ORAL DISEASES AND SURGERY. 

Disinfecting thoroughly the canal, or canals, as the tooth may be of 
a single root or of several roots, using for such purpose plain water 
thrown forcibly into the cavities by means of a tooth-syringe, 
the test is to be made by preparing a most delicate twist of cotton, 
which in length may double that of the tooth. This twist, being 
moistened in a weak dilution of creasote, in phenate of soda, oil of 
cloves, or in the glycerole of thymol, — as now preferred by many, — 
is to be taken up with the point of a delicate root-plugger, and, 
being carried as deeply into the root as possible, fold after fold is 
to be forced upon it until the space is solidly packed. The canal 
thus plugged, the chamber proper of the pulp and the common 
cavity of decay are to be filled either with white wax, with gutta- 
percha, or, what is found to answer most satisfactorily, a tuft of 
cotton which has been partly saturated with gum sandarac. 

A manner of filling canals temporarily, which will be felt to com- 
mend itself, consists in employing threads of the ordinary gilling 
twine. The canal being cleansed, the thread, holding the antiseptic, 
is carried into the cavity, and packed precisely in the same way as 
the cotton ; an end of the thread is, however, to be allowed to extend 
to the orifice of the common crown cavity, that thus the packing 
may be most easily extracted when required. 

The length of time which a test filling is to be allowed to remain 
varies with almost every case. As a direction which may serve for 
a principle, it may be said that when, after a single day, a closed 
cavity remains perfectly comfortable, — the patient affected by no 
consciousness of the presence of the tooth, — and when, on the with- 
drawal of the test, complete cleanliness is to be recognized in the 
absence of offensive odor, such a pulp cavity may be esteemed in 
condition to receive the permanent filling. Very often, however, it 
is seen to happen that a test filling is so poorly endured that its 
presence for a single half-hour will develop symptoms of periodonteal 
irritability, the tooth becoming sore to the touch and sensitive to all 
impressions. Here we have nothing to do but remove the test, 
applying soothing applications, the solution of the atropiae sulphas 
being among the very best that may be used. The cavity is now to be 
loosely filled with cotton, or it may be left open, and allowed to rest 
until the irritability has subsided, when, a few days or a week having 
elapsed, the test filling may be again tried. 

In cases, however, where in single-rooted teeth resistance is 
continuous, it is implied that a suppurating surface exists on the 
external face of the root, and that the discharge or oozing finds its 



THE TEETH AND THEIR DISEASES. 



387 



vent through the canal. In these cases, while the operator may, if 
he please, try stimulating injections forced through the foramen, 
trusting thus to find himself able to break up the morbid action, a 
plan which will be practiced with much more satisfaction consists 
in the immediate permanent filling of the canal with gold, and the 
making of a counter-opening through the alveolus, such opening 
being kept patulous by the use of a tent of cotton. No better plan 
of treating a suppurating periodonteum may be adopted than using 
injections through a counter-opening as thus made. 

In the case of the multi-rooted teeth resisting the test filling, trial 
is to be made until the particular fang diseased is discovered. Such 
information is quickly elicited by treating each canal separately, the 
diseased one alone responding: this one discovered, it is to be filled, 
and the counter-opening made as directed. 

Quiet existing in a pulpless tooth, the filling of the root canal is 
accomplished as follows. Take a sheet of gold (say, for illustration, 
No. 5) ; cut it into four strips. Take one of these strips, and, fold- 
ing it once upon itself, run it into a spiral upon a broach or a common 
pin. Take now this spiral, and, dipping the point in creasote, carry 
it by means of a foil-carrier into the canal ; if it has been solidly 
rolled, it may be forced at once quite to the apex of the root. 
Following the carrier with a root-plugger (Fig. 130), the spiral is to 



Fig. 130. — Nerve-Canal Plugged 



1 2 




be condensed by forcing turn into turn, spy-glass fashion. Of the 
remaining pieces, cylinders may be made of such varying sizes as 
may seem required for the operation. 

The canal proper sealed, the pulp chamber is to be filled with the 
oxychloride of zinc, this second agent being interposed as a non- 



388 ORAL DISEASES AND SURGERY. 

conductor between the filling in the root and that which is to occupy 
the cavity in the crown. 

Another method of using the gold consists in taking a strip of 
heavy foil (say No. 20), and, cutting off a delicate thread, carrying it 
by a point to the apex of the canal. The plugger, fixing thus the 
initial extremity, is to be slightly withdrawn, and the thread, portion 
by portion, crimped upon itself until the canal is full. 

Still another manner of treating a canal, and the one which is 
perhaps most frequently practiced, consists in filling first the apex 
of the canal with a twist of cotton which has been impregnated with 
creasote. Upon this cotton is packed the gold, as directed. In 
introducing the cotton, it is only necessary to make a twist, the 
initial extremity of which shall be of the greatest tenuity. This 
initial end, or as near it as may be possible, is caught upon the end 
of the root-plugger, and, being carried to the apex of the canal, the 
remainder of the twist is crimped upon it. Operators of repute are 
found whose commendation of the cotton plugs extends to their em- 
ployment in filling the whole canal. Such free use, however, of so 
loose a material may not be indorsed except for teeth of the most 
solid structure. Gold is, without doubt, the very best material 
which may be used, sealing as it does the cavity with an impervi- 
ousness which is the highest requirement of all such cases. A 
common fault with canal fillings of gold is that the operator fails in 
carrying the metal to the apex of the cavity, thus permitting the 
existence of a receptacle in which accidental deposits at once 
become foreign, being removed from the functional offices of vital 
parts which are alone capable of a demanded antagonism. A canal 
solidly full to the very foramen, any exudate which may occur must 
be associated necessarily with absorbent vessels which adjoin, no 
road of ingress into the tooth canal being open. 

A source of disease equally to be guarded against exists in the 
accident of forcing the root filling entirely through the foramen. 
This may occur only where foramina are enlarged, either because 
of natural condition or from absorption. Such an accident the prac- 
titioner may guard against by informing himself as to the condition 
of the opening through exploration by the broach. If the part is 
normal, the sense of touch will discover to him a closed cavity ; if 
abnormal, he will feel the instrument impinging upon soft parts 
which will be associated with pain to the patient ; or, where a fora- 
men is not specially enlarged, the broach will be felt to enter a con- 
striction. A discovery thus made, the filling is influenced in the 



THE TEETH AND THEIR DISEASES. 389 

depth to which it is to be carried, by a measurement secured by the 
broach. 

In the use of so delicate an instrument as a broach, great care 
is to be exercised that the instrument shall not become jammed in the 
canal, — perhaps, as has been the case, in the foramen, — and, break- 
ing-, leave a cause of offense which may result not alone in the loss 
of the tooth, but which, in more than a single instance, has caused 
loss of life from tetanus. Should such accident occur, every effort 
is to be made to remove the broken fragment ; the desired result 
being generally attained by catching the piece in a wisp of dry 
cotton revolved about it by means of a second broach. Where a 
broach has been caught and broken in the foramen, it will be found 
necessary to enlarge the opening by means of the spear-drill, — a 
practice the necessity for which will be found unfortunate, as almost 
invariably does it result in necrosis of the root so treated. 

The conducting facility of gold being well recognized, the use of 
a non-conducting substance placed between the plug in the canal 
and that which is to occupy the crown is appreciated. Teeth not 
so treated are subjected to a source of continuous irritation to which 
very many succumb, a chronic inflammation, resulting in necrosis, 
being the result of the varying thermal impressions. Founded on 
such experience, the practice therefore is pursued of filling the pulp 
chamber proper — that is, that cavity out of which run the canals — 
with such preparations as the oxychloride of zinc or gutta-percha, 
the former to have the preference. 

The canal and pulp chamber of a tooth filled, experience demon- 
strates the desirability of rest to the organ of a few days before per- 
forming the crown operation, the cavity to be temporarily filled with 
a sandarac cotton plug. 

Filling over Exposed Pulp — So common has the practice now 
become of attempting the performance of the filling of complicated 
cavities and, at the same time, the saving of the pulp, that in the 
operation dental writers, in their multitudinous suggestions, are too 
frequently found forgetful of the general principles which underlie 
necessarily all such character of manipulations. 

Upon a former page, mention was made of three sequelae associated 
with exposure of the pulp. These three conditions are as naturally 
conjoined with the relation as is the immediate union of a wound 
with hyperplastic blood, or non-union with the extremes of syphilis 
and scrofulosis. Whether, therefore, or not, it is worth while to 



390 ORAL DISEASES AND SURGERY. 

attempt the saving of an exposed pulp, will depend exclusively and 
strictly upon the common condition of the individual. 

That the vitality of an exposed pulp may be preserved, and a tooth 
so affected be treated and filled, is a fact attested by record too reli- 
able to be denied ; but that such success is associated more closely 
with physiological relation than with mechanical skill requires only 
experience to become to every observer a self-evident fact. 

Assuming the existence of such condition as shall justify the 
attempt to save an implicated pulp, attention may be invited to the 
methods of practice found by experience to be the most applicable. 

Taking, as a first illustration, a case where the pulp should be 
scarcely exposed, but be found overlaid by a layer of devitalized 
dentine, it has become the quite common practice to trust such layer 
to the offices of nature, allowing it to remain, rather than expose the 
pulp chamber, trusting that through some means the foreign body 
may be taken care of,* — a desired result which does not unfrequently 
occur, as case after case on record satisfactorily exhibits. In placing 
a filling, however, over such diseased dentine, it is desirable first to 
put it in a state of neutrality; that is, tests are to be made for acid 
or alkaline conditions, and, if either state be found, it is to be an- 
tagonized; fungi, an almost constant inhabitant of such devitalized 
dentine, are to be destroyed : in short, if vitality may not be restored, 
causes of change and disintegration are to be removed. 

A plate of living dentine, be it ever so thin in the centre, but 
having circumferential relations sufficient for the maintenance of its 
vitality, is to be viewed as a condition which, properly assisted, 
will tend to grow better rather than the reverse. 

A plate of dentine, on the contrary, with very limited parietal 
relations, will be found much more disposed to degenerate than to 
maintain or increase its resistive force. 

Cavities of decay opening into the pulp chamber are treated in a 
variety of ways. Of the means adopted, the various modes em- 
ployed will with advantage be studied, as it is a common experience 
that the unsatisfactory and unreliable character of any or all of them 
tempts the practitioner to try each in its turn. 

A means at the present time enjoying the largest favor is the 
employment, as a capping, of the preparation described as the ox} r - 

* A layer of devitalized dentine may be liquefied and absorbed, or it may 
become encysted ; that is to say, between it and the pulp may be deposited a 
layer of secondary dentine. 



THE TEETH AND THEIR DISEASES. 391 

chloride of zinc. It has, however, become a too common habit to 
treat of this substance as a specific in the direction, and with such 
false impression it is every day used by many with a recklessness 
which has no excuse. That oxychloride of zinc is a most admirable 
agent in such direction, employed with a judicious care, is certainly 
not to be denied. No substance introduced into a tooth seems to 
exert greater influence in the excitation of that action which pro- 
duces secondary dentine than does it; but injudiciously employed, 
no compound more quickly provokes antagonistic inflammatory 
action. 

In using oxychloride, it certainly is not to be understood that it 
may be plastered over an exposed pulp ad libitum ; on the contrary, 
if it is to be used with any prospect of satisfactory result, every 
consideration is to be had to the delicate and susceptible nature of 
the organ to be treated. Oxychloride of zinc placed directly upon 
an exposed nerve could only have good results by an accident which 
should just level the break in the continuity of the floor of the 
cavity, and which should have alone that most happy vascular 
response which tends to the formation of secondary dentine. These 
results, however, are precisely what are claimed as the rule by 
the supporters of the practice ; the proof or disproof of the claim 
the reader will, without doubt, incline at some time or other to 
make for himself. 

Oxychloride is recommended in this volume as a capping; indeed, 
the experience of the author would lead him to esteem it as the most 
valuable of the agents employed, — and thus far does he fully agree 
with its enthusiastic admirers ; but whether it is to be used with 
an excess of the chloride, or with this powerful excitant neutralized 
as much as possible by the inert oxide, must depend entirely on the 
character of the tooth treated. Again, the preparation is not to be 
brought, in its plastic state, into direct contact with the pulp, but 
always is it the safer practice to have an interposed plate. As the 
material of such a plate, oiled paper may be used. 

Again, in the use of this agent it is the best plan to feel one's 
way ; success will not unfrequently be secured by letting the appli- 
cation as first made be so thin a film as may alone prove self-sup- 
porting. Upon such film, if no response is made, a second may be 
placed, and upon this second a third ; the cavity being finally filled 
complete, and to be thus allowed to remain until, from continued 
or accruing comfort, there is reason to infer that the pulp has 
entirely accommodated itself to the new condition of things, or, 



392 ORAL DISEASES AND SURGERY. 

otherwise, has walled itself in by a secondary deposit, — a period of 
from one week to a year. 

Perhaps always is it the result that pain, more or less severe, is 
experienced by the patient upon the introduction of this preparation. 
Particularly will this be found the case where the mixture has been 
prepared thin, or where a local anaesthetic has not preceded the 
application. When such pain continues longer than a few minutes, 
it will be found the safer practice to remove for the time being the 
filling, or otherwise it will be necessary to call off the persistent 
irritability through the means of counter-irritants applied to distant 
parts, and also to diminish the circulatory force by the exhibition 
internally of veratrum viride. By such means it is not unfrequently 
the case that quiet may be restored and the desired protective con- 
ditions secured. 

In a pulp chamber fairly exposed a process of capping commends 
itself. Of the means and manner of this manipulation there will be 
found several. A mode of making and applying a cap indorsed by 
many experienced operators is thus described by J. A. Kennicott, 
D.RS. : 

" A cap is to consist of two materials of opposite nature : the one 
rigid and firm enough to support the greatest possible pressure that 
it may receive in the process of filling the cavity without yielding, 
and the other soft and yielding enough to take a perfect impression 
of the pulp without injurious pressure. Neither material must be 
corrosive in the slightest degree ; nor must there be any incompati- 
bility between these and the nerve. The plastic material, or that 
which comes next the nerve, must also be essentially non-conducting 
and indestructible. The two materials thus needed are found in 
gold and gutta-percha. The operator should have a quantity of 
caps prepared from thin gold plate, of various forms and sizes, so 
that he may select one to fill any cavity. They must be swedged 
up with a punch, in a concave form, and the edges made thin and 
smooth with the file, or a die might be constructed to cut and shape 
them of the required form and size, all at the same operation. Some 
will require to be round, some oval, and some pyriform. The gutta- 
percha, which can be procured in the shops in the liquid form, should 
be evaporated to dryness, then cut into pieces ranging in size from 
a grain of mustard to a No. 10 shot. After selecting a cap, which 
must be large enough to cover the exposed pulp and rest upon a 
solid margin of dentine beyond it, the operator will place in it a 
piece of gutta-percha sufficiently large when melted to fill the con- 



THE TEETH AND THEIR DISEASES. 393 

cavity and to extend somewhat above it. Then hold the cap over 
the flame of a spirit-lamp until the gutta-percha is melted, and with 
a smooth-faced plugger, the point of which has been warmed and 
slightly smeared with the melted gutta-percha, touch the convex 
side of the cap, when it will adhere, and afford a very convenient 
means of conveying it to the required position in the cavity. Now 
warm a larger instrument to about one hundred and twenty degrees, 
and place it against the cap and press it gently down until it rests 
firmly upon the surrounding hard parts, and until the surplus gutta- 
percha escapes from beneath it. This surplus material may be 
removed, or it may be left as a protection to the sensitive dentine. 
It is essential that the gutta-percha be warmed until it is sufficiently 
limpid to adapt itself, without sensible compression, to the delicate 
soft parts. 

" In case a portion of the nerve has been destroyed, the walls of 
the pulp cavity should be countersunk with a proper drill nearly to 
the exposed surface of the remaining portion, and the balance of the 
operation proceeded with as already described." 

The mode just described is modified by some, who, deeming the 
gutta-percha to be rather a source of offense than of protection, leave 
it out of the cap. Still another modification consists in filling the 
cap with the oxychloride, and, when this has become hard, cutting- 
it out in concave form and thoroughly polishing the surface. 

A second mode of capping an exposed pulp consists in taking a 
piece of clarified quill, and, cutting and scraping it into a required 
shape and thinness, laying it over the break, the circumference being 
supported by the bounding hard parts. While held in place with 
a delicate instrument, it is to be fixed by a plug of oxychloride of 
zinc being placed upon it, this zinc being afterward removed in 
part for the accommodation of the permanent filling. 

Still another manner of accomplishing the proposed protection is 
found in the use of a layer of oiled silk or vellum. These are most 
suitable as non-conducting qualities are considered, but are objec- 
tionable as permanency is concerned. 

Other preparations used for capping are lead, tin, asbestos, and 
the Hill stopping. A plan which many think to be commended 
by results consists in inclosing asbestos between layers of gold-foil, 
and, with the metal thus stiffened, arching it over the exposed pulp. 

Dr. Alport, of Chicago, a skillful dentist, has proposed — and pro- 
fesses to have practiced with a success entirely satisfactory — the 
following delicate operation : Exposing fully the pulp, he takes out 



394 ORAL DISEASES AND SURGERY. 

of the body of the organ a Y-shaped piece, bringing afterward the 
lips together, and so retaining the apposition as to secure an imme- 
diate union. The necessity for such an operation, however, might 
only occasionally apply. 

In the case of a pulp exposed, with the orifice of the exposure 
being jagged, sharp, and irregular, necessit}^ exists for such enlarge- 
ment and dressing of the same as shall insure the organ — enlarging 
from time to time, because of functional office — from irritation and 
strangulation. To accomplish such dressing, it will be desirable to 
constringe the pulp by such means as may be found best to answer 
the end. Tannin in a menstruum of glycerine is a favorite prepa- 
ration with many. Alum-water is an excellent application ; the 
tincture of nutgalls is another. 

A very effective plan consists in conjoining with the local means 
hot foot-baths, calling the excess of blood away from the head ; also 
the administration of medicines which tend to diminish the pro- 
pulsive force of the heart, — the tincture of veratrum viride being 
perhaps the best of such agents. 

An orifice, as described, being enlarged and dressed, capping is to 
be resorted to. 



CHAPTER XVI. 

THE EXTRACTION OF TEETH. 

Indications for Extraction.- — 1. Teeth, or roots of teeth, which 
have lost their vitality, and which have become so much loosened 
a's to be agents of offense and injury to surrounding parts. 

2. Posterior teeth, which, from absence of antagonizing teeth, are 
rising from their alveoli, and, through the displacement, have become 
a source of pain or inconvenience. 

3. Teeth having fungoid excrescences growing from the pulp 
cavity. 

4. Teeth having associated with them incurable abscesses, threat- 
ening complications. 

5. Teeth, particularly the premolars, so crowded and wedged 
into the arch as to contribute to undue lateral pressure. (See page 
142.) 

6. Posterior teeth inferred to contain nodules of osteo-dentine, 
being themselves painful, or associated with sympathetic neuralgia. 
(See page 374.) 

7. Teeth recognized as associated with antral disease. 

8. Teeth that are worn into the pulp cavities (see page 378), or 
so close upon the gums as to render mastication painful. 

9. Teeth so badly affected by caries — being painful or offensive 
— as to afford no prospect of usefulness. 

10. All roots of teeth about which the gums are congested and 
debased. 

11. All roots which are sources of pain or discomfort. 

12. All roots in which decay is progressing. 

The extraction of a tooth is an easy or difficult matter, according 
as the principles involved in the operation are clearly or obscurely 
comprehended. In the adult mouth there are thirty-two teeth, and 
these, as the study of their extraction is concerned, are compre- 
hended under six classes. 

(395) 



396 



ORAL DISEASES AND SURGERY. 



The first of these classes embraces the eight central and lateral 
incisors, teeth with cone-like roots, and accommodated in alveoli 
representing hollow cones. 



Fig. 131. — Permanent Teeth of Upper Jaw. 

hi m w if ww f §m. wn w r 

■ 11 If III IBf IB' Hi if ■■■iff BT w 
it ■■ IB/ IB ■! ™ IB W wmi w 


^1 


Mil : --MV flH •!■■ IK -JHBI SSEE 91 

/MBnlilV ffflH\\\ /in^Hw 'iHii' 4Hir fill I ' 

■1 III •' •!' 'Hit fllH BBS) ■■ 

HH iH w y war W/f 1 wSWWI ■ ^Bf / '■fill 
i a s' 4 ; 5 e. 7".'" ■- 8 


1 . 



I 


f 


|f f MW 


■^"""^"''''iiiiillllB 

■«P i> ''l >ll ' ,:, '7ffl^H 


1 


■1 

BV IB 




3 



Figs, 131, lo2: Diagram of Teeth. — 1, 2, incisors; 3, 4, 5, bicuspidati 
large molars, or grinders. 



>r small molars ; 6, 



The second class embraces the cuspidati, represented by the partly 
flattened cone. 

The third class embraces the bicuspidati, represented by the flat- 
tened cone. 

The fourth class embraces the superior first and second molars, 
teeth having three roots, — two external cone roots, situated antero- 
posterior^, with the interspaces looking toward the cheek, and the 
third, generally a flattened root, looking toward the palatine arch. 

The fifth class embraces the inferior first and second molars, teeth 
having two roots, one looking anteriorly, the other posteriorly ; the 
interspace looking outward and inward. 

The sixth class embraces the four wisdom-teeth. These are 
single-rooted as a rule, with a curve looking backward. 



To extract a tooth of the first class, the application of the force is 



THE EXTRACTION OF TEETH. 397 

required in a twofold direction, rotatory, and downward or upward, 
as the case may be. 

To extract a tooth of the second class, the force is required in a 
threefold direction, downward or upward, lateral, and rotatory. 

To extract a tooth of the third class, upward or downward, and 
lateral, or inward and outward, as one loosens a nail. 

To extract a tooth of the fourth class, the same application of the 
force ; one-half of such a tooth is, however, to be extracted at a 
time, — that is, we first break the attachment of either the inner or 
outer roots, and, feeling" these yield, the force is instantly brought to 
bear upon the other. In extracting teeth of this class in this man- 
ner, much care is necessary in guarding against a too great extent 
of lateral motion ; otherwise the roots, instead of yielding, will be 
found to break, thus complicating matters very seriously. 

Teeth of the fifth class require the lateral and direct application 
of the force ; they are to be gently rocked inward and outward until 
felt to yield, when they are at once to be lifted from their sockets. 

Teeth of the sixth class are to be carried backward and upward, 
or downward, in the line of the axis of their single curved root. 
Such applications will make easy an extraction which might other- 
wise be attended with much risk. 



INSTRUMENTS. 

Instruments are now made in consideration of the anatomical 
peculiarities of the teeth for which they are intended. The better 
class are nickel-plated, to insure against rust, and are of such 
quality, as the character of the steel is concerned, that they will 
retain the outline and sharpness of blades through much service. 
No instruments but those of such quality are worthy of purchase. 
We now describe, with manner of use, such as have most com- 
mended themselves. 

Fig. 133. — Upper Incisor. 



398 



ORAL DISEASES AND SURGERY 
Fig. 134 — Upper Lateral Incisor. 

CZ 




Fig. 135. — Lower Incisor, Hawk-Bill. 




Fig. 136. — Lower Incisor and Bicuspid, for Eittter Side. 




Fig. 137. — Hawk-Bill, Lower Incisor, and Crowded Teeth. 

lH Hi 




Figs. 133 to 137 represent forceps designed for the extraction of 
the incisor teeth. Referring to Figs. 131, 132, Nos. 1 and 2, or, 
what is practically much better, examining the organs themselves, 
the reader will perceive that these teeth fully represent, as we 
have stated, double cones, the bases abutting just beneath the free 
margin of the gum. To secure a fixed, unyielding hold of a body 



THE EXTRACTION OF TEETH. 399 

so shaped, it would strike the intelligence of any operator that the 
forceps should be so constructed as to accommodate the width of 
the base, yet at the same time grasp firmly the retreating cones. 
Turning here the examination to the forceps, these indications are 
found to be fully met. The fenestrum, made when the blades are 
closed, forms an ellipse, the widest part of which corresponds with 
the base of the teeth. The apices correspond so in form with the 
cones, and the concavities of the blades so adapt themselves, that, 
applying the instruments, they are found fitted to the teeth with the 
nicest accuracy ; indeed, as suited to the purpose, nothing seems left 
to desire. 

Fig. 133, upper incisor, is a straight forceps, designed for the 
superior incisors, and which, where the under jaw is well withdrawn, 
answers very well for the cuspidati. The roots of the incisor teeth 
are understood to be rounded cones, having corresponding alveoli. 
These teeth are, perhaps, the most easily extracted of any in the 
jaws. Thrusting the blades well beyond the neck of the tooth, the 
curve in the handle receiving the little finger, and looking towards 
the body of the patient, having the head resting either in the 
support of the ordinary dental chair, or against the chest of the 
operator, whose left arm is to be thrown around it to secure fixed- 
ness (and which position applies to all the upper teeth), a force is 
to be applied, which, while drawing downward, rotates or twists 
the organ from its socket. If, however, the resistance prove too 
great for a single twist, — which, in heavy jaws, is almost certain to 
be the case, — then the motion is to be reversed, the direction of the 
twist being alternated until the tooth is felt to yield, when, without 
further effort, it may be drawn from its socket. 

Fig. 134 represents a forceps designed for the upper lateral incisors. 
The ellipse is seen to differ a trifle from that of the preceding instru- 
ment; this adapts it to a corresponding difference in the tooth. It 
differs principally, however, in having the blades made narrower. 
The application of this forceps is precisely the same as that em- 
ployed in the case of the central. 

Figs. 135 to 142 represent forceps, all of which find an adaptation 
to the inferior incisors, central and lateral, the cuspidati, and the 
bicuspidati. 

When directed to these teeth, the operator may stand either in 
front of his patient, or (a position more commonly preferred) he may 
seat the patient upon a low chair, leaning over his head, or over the 
right or left shoulder, as found most convenient. 



400 ORAL DISEASES AND SURGERY. 

Fig. 138. — Upper and Lower Root, Half Curved. 




Fig. 139. — Lower Root, Full Curved. 




Fig. 140 — Upper and Lower Bicuspid, Half Curved. 




Fig. 141. — Upper Back Root (universal). 




Fig. 142. — Half Curved, Narrow Beak, for Crowded Teeth. 




Fig. 141 is also a forceps adapted to the extraction of the inferior 
incisor teeth. Grasping the tooth by forcing the blades as far down 
as possible, keeping them confined closely to the organ, that thus 
they may be directed between the tooth and its alveolus, the rounded 
root of the central may generally with much ease be broken from its 



THE EXTRACTION OF TEETH. 401 

attachments by an upward and rotatory movement. If, however, 
with a very reasonable application of force so applied it is not felt to 
yield, the strain is not to be increased to a risk of breaking the tooth, 
but a lateral motion inward and outward may be tried, or this con- 
joined with the rotatory. This root being sometimes considerably 
flattened, makes such lateral motion necessary. If very narrow or 
crowded, the forceps represented by Fig. 142 may be used. In re- 
moving the inferior lateral incisors the rotatory movement is to be 
employed, which may have combined with it slight lateral motion, 
although this latter will not be found of much import, unless in 
exceptional cases, where the roots happen to be markedly flattened. 
The bicuspidati all have flat roots, and, so far as the conditions of 
extraction are concerned, are to be viewed as possessing but a single 
root. These teeth are to be removed just as a nail is worked from 
a board into which it has been loosely driven, — a motion inward and 
outward quickly breaking the attachment. The position of operator 
and patient is the same as just suggested. 

Fig. 143.— Upper Bicuspid and Canine. 




Fig. 143 designates a forceps adapted equally well to the ten ante- 
rior upper teeth. It may justly be termed a faultless instrument. 
For myself, I certainly give it the preference over all that I have ever 
seen for the purposes intended : indeed, I incline to think that with 
it any tooth in the mouth could be extracted in an emergency. 
Applying this instrument to any one of these ten anterior teeth, it 
is seen to be possessed of most satisfactory adaptation, the curve 
in the blades and handles clearing the lower lip to an extent afford- 
ing the greatest freedom in motion, while the support curve in the 
handle prevents the possibility of change in the grasp. 

The root of a cuspidate is perhaps the most firmly fixed in its 
alveolus of all the teeth of the jaw. Occup}dng as it does the po- 
sition of a keystone to an arch, to extract this tooth both strength 
and skill are required. In shape, the root is found to be a partly 

26 



402 



ORAL DISEASES AND SURGERY. 



rounded, partly flattened cone; its alveolus, of course, corresponds. 
In length it is greater than the adjoining teeth, — in many instances 
to the extent of a third, — and, while generally straight, is yet fre- 
quently to be met with having an apex curved at varying angles, 
such curvature, however, being confined to the extreme end. To 
extract this tooth, the organ is grasped by working the blades of the 
forceps as much below the edge of the process as possible, and, while 
a firm compressing force is maintained, the tooth is gradually ro- 
tated, and also worked inward and outward. If, after a moment, 
it should be felt to yield, and yet, while moving with more or less 
freedom in its socket, seem to be held by some attachment, the 
operator is to cease his efforts, that he may satisfy himself that the 
loosening resides not in a fractured alveolar process or in a retaining 
flap of gum. If neither of these complications exists, he may again 
seize the tooth, and, understanding that the retention depends on 
curvature of the fang, attempt to get it away by finding, through 
various movements, the direction which affords the least resistance : 
this discovered, it is to be worked out even at the risk of fracturing 
the curved apex. No tooth requires to be more thoroughly and deeply 
lanced than the canine. 

Fig. 144. — Upper Bicuspid and Incisor. 




Fig. 145. — Lower Bicuspid and Canine. 




Figs. 140, 1 43-141, are instruments designed by different oper- 
ators for the extraction of the bieuspidati and cuspidati. These 



THE EXTRACTION OF TEETH. 403 

forceps will be remarked to vary considerably in shape. Fig. 140 is 
one found to have most frequent application, being useful alike in 
the superior and the inferior jaw. Unless it is designed to furnish a 

Fig. 146. — Lower Bicuspid, Safety. 




Fig 147. — Upper Bicuspid, Safety. 




case with all the numbers, this may with most satisfaction be 
selected. Fig. 145 is an excellent instrument, particularly appli- 
cable to the lower jaw when the teeth are set well back and the 
commissure is small and unyielding. 

Fig. 148. — Upper Molar, Eight and Left (Harris's). 




Figs. 148 to 151 represent forceps designed for the extraction of 
the superior molar teeth. On examining the blades of any of these 
instruments, the outer will be seen to run to a nib at its centre, 
while the inner is plain. These correspond with the anatomical 



404 ORAL DISEASES AND SURGERY. 

Fig. 149. — Upper Molar, Eight and Left. 




Fig. 150. — Upper Molar, Eight akd Left 



Fig. 151. — Upper Molar, for Either Side. 




indications of the teeth upon which they are to be used, as is seen 
by glancing at Figs. 131, 132, Nos. 6 and 7. To apply these forceps, 



THE EXTRACTION OF TEETH. 405 

the triangular blade must correspond with the outer face of the tooth. 
Having the instrument well in position, which, it will be recognized, 
places the point of the outer blade in the interspace made by the 
bifurcation of the buccal roots, and the concave plain inner blade 
against the palatine root, the force is to be so applied as to break the 
attachments at separate motions ; this is easily accomplished by 
the process of rocking the tooth outward and inward. A lateral 
movement is not to be great, that fracture may be avoided. The 
position of operator and patient is as before described for other 
upper teeth. 

It is not always the case, however, that these teeth are found as 
represented in the drawing. Sometimes as many as five roots exist, 
and these so diverging as to render the extraction of all of them, 
without fracture, a very difficult matter, perhaps indeed impossible, 
particularly if the jaw be heavy and the alveolar process dense. At 
other times it will be seen that the roots have commingled, forming 
an irregular conical fang. This latter condition facilitates, of course, 
extraction. Another condition not unfrequently met with is a con- 
vergence of the apices of the roots, these so grasping the inclosed 
process that, in the coming away of the tooth, either the fangs must 
spring to such extent as to permit the passage, or this piece of bone 
must come with it. 

Again, it is sometimes seen that a molar tooth — although this is 
much more common to the bicuspidati — stands to the inside of the 
arch, being wedged, as it were, out of its place. Here the rocking 
motion is necessarily modified. The tooth is first, with gentle yet 
steady force, to be carried inward, then back to the point of 
departure. This is to be repeated until the attachments are broken. 
Cases also present, but they are very rare, where a tooth desired to 
be removed is more or less overlaid by its fellows. Here it will 
most likely be necessary to resort to the use of the file, or recourse 
may be had to wedging away the opponent teeth by means of slips 
of india-rubber worked between the teeth while held on the stretch* 
Such wedges, after being retained for a few hours, will not unfre- 
quently be found to secure room quite sufficient for the passage. 
Where undue crowding is found to depend on proximal caries of 
the tooth to be extracted, it will be found all-sufficient to chisel 
away the part intruded on. 

Instrument Fig. 151 is of such construction as to permit its appli- 
cation to the superior molars of either side. It is, of course, not an 
anatomical forceps, but when the teeth to be extracted are solid and 



406 



ORAL DISEASES AND SURGERY. 

It is not, however, to 



resistive it answers its end tolerably well. 
be commended. 

Fig 152. These are instruments, in pairs, designed for the extrac- 
tion of the superior molar teeth. They are known as the Maynard, 
or cow-horn. Than these forceps, it would seem that none could 
be devised meeting more happily the anatomical requirements of 
Class IV. 

Fig. 152. — Upper Molar, Right and Left, Cow-Horn, with or without 
Hook on Handle. 




The outer beak, horn-shaped, is designed to enter the interspace 
between the buccal roots ; the inner — flat, square of blade, and 
grooved — adapts itself accurately and firmly to the palatine fang. 

To apply these forceps, the operator stands to the right of his 
patient, precisely as in the case of teeth of the first three classes, the 
left arm passing around the head, the fingers of the left hand holding 
the lip out of place. In using the Maynard forceps, care must be 
taken to thrust the point of the horn directly into the interspace, 
otherwise the operator would have no hold on the tooth: this being 
in position, the flat blade is carried along the palatine fang as high 
as possible. A few rocks of the tooth inward and outward, com- 
bined with a direct force in the line of its long axis, and it will be 
found to give way. 

Fig. 153 is an instrument of similar construction, differing, how- 
ever, in an arrangement of blade-curvature which permits of its 
application to the teeth of either side. 



THE EXTRACTION OF TEETH. 407 

Fig. 153 —Upper Molar, Cow-Horn, Either Side. 




Fig. 154 is a forceps intended for the lower molars and the dentes 
sapientise of either side. The molars of the inferior jaw are two- 
rooted (see Figs. 131, 132), with the interspace looking outward and 

Fig. 151 —Lower Molar, Either Side (Harris's). 



inward. Examining the instrument, it will be seen that the blades 
terminate in sharp, central nibs, the design of such points being 
to fit as accurately as possible the depressions made by the division. 
When the crown of a tooth is strong and resisting, or where a loose 
process permits of a hold which carries the nibs well into the inter- 
space, this instrument may be used to most satisfactory purpose. 
Where, however, the crown is much decayed, and consequently frail, 
the cow-horn forceps, next to be described, will be found better 
adapted. 

The wisdom-teeth of the lower jaw have the single curved root 
corresponding with the upper, bending here toward the rami of the 
jaw. Instrument Fig. 154 allows of the proper application of the 
force demanded for their extraction ; they are to be lifted upward 
and backward. Wisdom-teeth crowded under the rami, and thereby 
unable properly to erupt, not unfrequently become the occasion of 
grave lesions. For instances of such complication, together with 
mode of treatment, see page 170. 

Fig. 155 is the lower cow-horn forceps. This instrument, designed 
to be used in the extraction of the lower molars, is one of the most 
effective in the collection. To employ it, care is to be taken so to 
apply the points that the closure of the handle forces them into the 



408 ORAL DISEASES AND SURGERY. 

interspace. Referring to Fig. 132, this interspace is seen to corre- 
spond with the exact centre of the buccal and lingual faces of 
the tooth, and, examining its relation with the alveolar process, it is 



Fig. 155. — Lower Cow-Horn Forceps. 




seen to be on a level with its border. When the blades of the in- 
strument are in position, it will be recognized that the points are to 
occupy this interspace; thus the pressure is exerted from below, and 
not at all upon the walls of the crown, affording, in this respect, 
such advantage that extent of decay or brittleness amounts to very 
little. The lifting power and leverage of this forceps are of such 

Fig. 156. — Lower Molar, Cow-Horn, Eight Side. 




Fig. 157. — Lower Molar, Cow-Horn, Left Side. 




character that it very frequently occurs that the mere closing of the 
handle will loosen the tooth. When, however, this does not occur, 
the tooth is to be rocked until the connection is felt to break. Ex- 
amining a tooth held in the grasp of this instrument, the points of 



THE EXTRACTION OF TEETH. 



409 



the blades will be found met in the interspace. Always, before 
applying the force, it is well to have the points thrust as deeply as 
possible below the free edge of the gum. When such precaution is 
not taken, and the sharp points do not reach the interspace, they 
are almost certain to produce fracture. This instrument is, of course, 
not applicable where caries has proceeded to such an extent as to 
have separated the roots. 

Figs. 156 and 157. These are the cow-horn forceps in pairs: 
the shape of the handles, and the curve for the rest of the little 
finger, add much to convenience of employment. Together, they 
make a very efficient set for lower molars. 

Fig. 158 is a forceps designed for the inferior molars; it is known 
as Wolverton's instrument. It is preferred by many as combining 
the advantages of the Maynard and Harris. 

Fig. 158. — Lower Molar, Either Side (Wolverton's). 




Fig. 159. — Lower Molar (Hutchinson's). 




Fig. 159 is a lower molar forceps. In a deep mouth, and where 
the tooth to be extracted is much concealed by one anterior to it, 
the curve of the blade will be found to render it of great service. 
Admirers of the instrument commend it particularly for the shape 
of the fenestrum. 

Fig. 160 designates the forceps for wisdom-teeth of upper jaw, 
either side. As a rule, these teeth are found to have but a single 



410 



ORAL DISEASES AXD SURGERY. 



root. This, in shape, is conoidal, with a curve whieh directs the 
apex toward the tuberosity of the bone. To remove these teeth 
with least effort and risk, this curve of the root is always to be con- 
sidered, requiring the extraction to be in the line of its axis. To 
accomplish such a requirement, the crown of the tooth, after being 
grasped in the beak of the instrument, is to be directed backward. 
This rolls it, as it were, wheel-fashion, from its socket. The forceps 
Fig. 145 will also be found well adapted for the removal of these 
teeth when thev may be small. 



Fig. 160. 



-UpPEK DeXTES SAPIEXTI.E. FOE ElTHER SlDE, WITH OR 

■without Hook. 




It happens, however, that in many instances the superior wisdom- 
teeth have three, or even more, bifurcating fangs: when this is the 
case, it is quickly to be recognized by the undue resistance offered to 
the employed force, and its direction. No rule may here be given 
outside of that which applies to the neighboring molars: the oper- 
ator, if the irregularity is very peculiar, feels his way by testing 
for the aspect of least resistance. 

Fig. 161. — Phtsick's Dextes Sapiextije, Either Side. 




Fig. 161 represents a forceps designed by the late Prof. Physick 
for the extraction of wisdom-teeth. The instrument is seen to 
represent a double inclined plane, and, in consideration of the neces- 
sity for throwing these teeth backward, is designed to be applied 
between the tooth to be extracted and the one directly anterior 
to it. The closure of the handle is expected to throw the tooth 
from its socket. 

It sometimes occurs, however, that these teeth, as seen in the 
superior tooth in the drawing (Fig. 131), have more than a single 



THE EXTRACTION OF TEETH. 411 

root ; and these roots, instead of being inclined in a common axis, are 
frequently spread out in various directions. In cases of this kind 
it is plain that the instrument would not apply. Another objection 
to its use lies in the injury apt to be inflicted on the anterior or ful- 
crum tooth; this not unfrequently having the enamel so crushed and 
broken as to expose the more susceptible dentine, and thus lead to 
caries. . Still another objection lies in the contusion inflicted on the 
periodontium, this membrane being occasionally so injured as to 
result in its severe inflammation. 

The ordinary key instrument, when lightly and delicately made, 
answers a very admirable purpose with this class of teeth. The 
roots being generally quite short, there is little of the common 
danger of alveolar fracture, and being but lightly set in their sockets, 
and easily yielding, the application of but very trifling force is 
required. 

In using the key, the fulcrum should be placed on the inner face 
and well back upon the tooth, the claw being upon the opposite face 
and well in front ; this application allows of the proper direction of 
the force, and admits of the easy and natural removal of the organ. 

Still another instrument emplo} T ed in the extraction of these 
teeth is the elevator. (Fig. 167.) 

To apply this instrument, the grooved face is laid against the 
antero-lateral aspect of the tooth, and, being carried down to the pro- 
cess, the hand is depressed so that the free edge of the blade alone 
impinges; the tooth is then pushed outward from its socket, and 
backward. When wisdom-teeth are but ordinarily adherent, this is 
an admirable instrument for their removal ; care, however, is neces- 
sary that it shall not slip from the tooth and inflict injury on the 
neighboring soft parts. Elevator No. 6 (see Fig. 167) is the one 
most commonly employed. 

Fig. 162 — Lower Dentes Sapiknti^e, Either Side. 




Another instrument yet is Fig. 162: long of shank, and with 
blades curved at right angles with the handle, it answers a most 
admirable purpose in the case of the inferior wisdom-teeth. 



412 



ORAL DISEASES AND SURGERY. 



Fulcrum Forceps. — These instruments, of which seven consti- 
tute a set, act on the principle of the key and elevator. A glance 
at their construction will exhibit the mode of application. That 
when skillfully used they are capable of meeting many emergencies, 



Fig. 163. 



Upper Incisors, Cuspids and Bicuspids, for Either Side 
of the Mouth. 




Fig. 164.— Lower Incisors, Cuspids and Bicuspids. (Two pairs, one for 
the right and one for the left side of the mouth.) 




Fig. 165. — Lower Molar. (Two pairs, one for the right and one for the left 
side of the mouth.) 





may not be doubted. The forceps of this class here figured are the 
invention of Dr. E. M. Jones, of Richmond, Ya. Another instru- 
ment of the same general character, which, in respect to the fulcrum, 
highly commends itself, is the invention of Dr. H. H. Perrine, of 
Marvland. 



THE EXTRACTION OF TEETH. 



413 



All instruments of this class are, however, but modifications of 
the key of Garengeot and of the elevator, and, in the deserved com- 

Fig 166. — Upper Molar. (Two pairs, one for the right and one for the left 
side of the mouth.) 




mendation they receive, serve to exhibit the virtue of the instruments 
they replace. The key, so long and so completely abandoned, should 



Fig. 167. — Elevators used in Extracting Eoots. 




414 ORAL DISEASES AND SURGERY. 

not be without its place in an instrument-case. With a variety of 
claws to fulfill the diversified indications, and with skill and care in 
the adjustment of the fulcrum, it is a most valuable addition. An 
advantage possessed, however, by the fulcrum forceps, is easier 
adaptation of the claw, together with a more direct oversight during 
the act of extraction. In applying either this forceps or the key, it 
is necessary to force the blade as deeply as possible along the root 
of the tooth, and so to arrange the pad that the pressure upon the 
soft parts shall be as little injurious as possible. Bruising and 
crushing the gums are the objections. 

Concerning the fulcrum forceps, much commendation has been 
received, — gentlemen of experience considering them an essential 
to a satisfactory success in this direction of practice. 

Extraction of Fractured Teeth and Roots of Teeth. — It not 
unfrequently happens that, in attempts to extract teeth, fractures re- 
sult; and such fractures must, of course, present the greatest variety 
of aspect, and require various resources for the removal of the parts 
left. 

Teeth of the first, second, and third classes present the same com- 
mon features of fracture, and may claim a first attention. Fig. 168 
represents the alveolar line, and the various relations held to this 
line, or free border, by fractured teeth or roots. 

Fig. 168. — Belation of Fractured Koots to Alveolar Line. 

1 2 3 4 5 6 7 




A fractured tooth, as represented by Subfig. 1 (the first root to 
the left), is placed in no worse condition for easy extraction than 
before the occurrence of the accident. The same forceps and the 
same manner of its application still apply to it. 

Subfig. 2 represents a slight modification of the same condition. 
The one forceps and the one application still, however, apply. It 
is advisable, if the tooth is at all brittle, to w r ork the blades of the 
instrument well beneath the alveolus. This affords greater support 
and yields increased security. 



THE EXTRACTION OF TEETH. 



415 



Subfig. 3 may represent a bicuspid tooth with the crown half 
broken away. In such a case, if the remaining portion is not at all 
brittle, and if the process is soft and spongy, the forceps, as de- 
scribed, having well-sharpened blades, may again be tried, working 
them well beneath the process, and securing all the hold possible on 
the root. If fracture again occurs, which, indeed, is very likely, 
simulating Figures 4 and 5, the cutting forceps is to be employed. 

To use a cutting forceps, make, with a scalpel or other blade, an 
incision on either side of the root through the soft parts directly 
down to the process; these cuts must correspond with the exact 
centre line of the root. The forceps is now to be applied scissors- 
fashion, cutting directly through the bone. Being thus brought in 
contact with the root, and grasping it perhaps full half its length, 
the removal is, of course, a perfectly simple matter. 

Some operators prefer to precede the cutting forceps with the 
elevator, and this instrument, in many cases, certainly effects the end 
very well. 

Iu the application of the cutting forceps, it not unfrequently hap- 
pens that, from want of care, the blades, instead of coming directly 
upon the root, slip to the back or front of it. Jn these cases the 
fang may generally be easily enough picked out with the ordinary 
root forceps. A form of cutting forceps used by many, consisting of 
a double curved blade, avoids this accident, but it is to be objected 
to on account of the wound it makes. 

Roots, represented in Fig. 168, Nos. 4, 5, 6, and T, are removed on a 

Fig. 169. — Inferior Combined Eoot Incising, Separating, and Ele- 
vating Forceps. (Dr. T. C. Stellwagen's Pattern.) 




common principle. The first attempt is to be made with the ele- 
vator : laying the groove of this instrument closely against the root, 
its sharpened knifelike edge is insinuated between the fang and pro- 



416 



ORAL DISEASES AND SURGERY. 



cess, being worked down as far as possible. The handle is now 
carried obliquely to the line of the root, and thus, with a careful 
oscillatory motion, the piece is forced from its bed. It is very well 
known, however, that with a dense, heavy, alveolar process, this 
instrument cannot be made to operate so happily, it being next to 

Fig. 170. — Superior Combined Eoot Incising, Separating, and Ele- 
vating Forceps. (Dr. T. C. Stellwagen's Pattern.) 




impossible to insinuate it between the bone and tooth. Under these 
circumstances, another instrument, the screw (Fig. 171), may be 
brought into requisition. 

Fig. 171. — The Screw. 




The screw is designed to operate upon the tooth root as the spiral 
operates upon the cork. Well tempered, and very sharp, it is intro- 
duced into the pulp canal, and quietly and gently turned until it has 
taken a firm hold. A simple direct movement, and the root is brought 
away. 

It may happen, however, that no hold sufficiently firm for the 
extraction can be obtained with this instrument When this is the 
case, it may be laid aside, and the always reliable cutting forceps 
brought into requisition. If preferred, however, the screw can be 
bored into the tooth until fracture is produced, and this will some- 
times enable us quite easily to pick away the splinters: particularly 
will this be found to be the case when the line of the fracture divides 



THE EXTBACT10N OF TEETH. 



417 



the root in its length. The forceps known as Dubs' and Hullihen's 
represent the combination of the screw with the forceps. In the 
Hullihen instrument the screw is designed more especially to afford 
support, preventing the blades from crushing the root. In the Dubs' 
forceps the spring trigger corresponds with the two forces, affording 
thus not only support, but allowing the extracting force to be divided 
between the two means. 

In using these instruments (their employment being confined to 
the single-root teeth), the shank holding the screw is to be confined 
in the grasp of the blades, and, thus controlled, it is to be screwed 
into the pulp cavity : a proper hold secured, the blades are to be 
expanded, and thrust, as in the ordinary application, about the root, 
which is then extracted secundum artem. 

In many instances, however, the immediate employment of the 
screw is found impracticable, owing to the shape of the canal or the 

Fig. 172. — Dubs' Screw Forceps. 




1, conical screw with square ratchet shaft; 2, beaks of forceps, grooved inside; 3, 
socket with square hole to receive shaft ; 4, spring trigger by which the screw can 
be detached at pleasure at any given point. 



Fig. 173. — Hullihen's Screw Forceps. 




density of the dentine : in these cases the fang is first to be reamed 
out, which manipulation is accomplished without effort by the use 
of drills. 

Roots of the molar and wisdom teeth, superior and inferior, are 
removed on a common principle. In the use of the elevator, a very 
happy result is not unfrequently secured by applying the blade to 

27 



418 



ORAL DISEASES AND SURGERY. 



the inner face of the root, carrying the shank across the mouth, and 
making a fulcrum of some convenient opposite tooth. 

Where the roots of a molar tooth are so firmly fixed as to seem 
incapable of removal with the application of an ordinary amount of 
force, it is better to divide them. This is easily done with the 
cutting forceps, and after the separation each root may be picked 
out singly, and generally with comparative ease. 



Upper Front Root, Straight. 




Pig. 175 — Upper and Lower Root, Half Curved. 




Fig. 176 —Lower Root, Full Curved. 




Fig. 177.— Upper Back Root (universal). 







Forceps of delicate beak are much in favor for the extraction of 
roots of teeth : indeed, it is a common practice to exhaust their 
capability before resorting to other means. Figs. 174 to 180 exhibit 
different forms of such forceps. Figs. 177 and 178 are to have the 
preference, — these being quite capable of performing the work of 
the others. 



THE EXTBACTION OF TEETH. 
Fig. 178. — Bayonet-shape Root. 



419 




Fig. 179. — Half Curved, Long Beak, Alveolus. 




Fig. 180. — Lower Molar Root (with Crowns). 




Deformed or Anomalous Teeth. — Understanding the principles 
on which teeth of ordinary character are extracted, the practitioner 
will need but little instruction so far as anomalies are concerned. 

In Fig. 181, Subfigures 1, 2, 3, 4, and 5, although so ill portrayed 
by the artist, sufficiently represent five anomalies, and these may very 

Fig. 181. 




well stand for the class. In removing such teeth from the mouth, the 
matter of greatest importance is to recognize them. Now, while 
this cannot in all cases be done so as to appreciate exactly the con- 
dition of the roots, yet we may always say that some impediment 
to the removal exists ; and this, after all, is the most important 



420 ORAL DISEASES AND SURGERY. 

matter, as it influences the amount of force exhibited, which, too 
freely rendered, might result in fracture of the bone, or still greater 
injury to surrounding parts. 

A tooth, as represented in Subfig. 1 (the first to the left), will 
generally yield in its roots so as to pass the intermediate piece of 
process. If it does not so yield, then this wedge of bone will frac- 
ture and be brought away. Such fracture, however, results in no 
harm, and is to be deemed of little consequence. 

Subfig. 2, by the great curve in the root, is made incapable of 
passage, unless, after being loosened, it is carried outward in the 
direction of the axis of the curve. In this way it is easily removed. 
The character of the curve is recognized by the resistance offered 
when the tooth is carried in certain positions, and by the absence of 
such resistance when it is carried in the proper line. The attempt 
to remove such a tooth by simple force would result either in frac- 
ture at the curve, in lifting out a neighboring tooth, or in fracture 
more or less extensive of the alveolar process. 

Subfig. 3 represents exostosis of a root. A tooth fang so enlarged 
will not pass through the process unless the bone is very open in its 
structure. Such a tooth may be made quite loose, but, while it 
moves freely enough in its socket, it is felt to be held by something 
abnormal. To free such a tooth, it is only necessary to use the 
cutting forceps, or, what I prefer, to take the ordinary small surgical 
chisel and cut away sufficient of the process to admit of the passage. 
This little operation is easy of accomplishment, and must prove 
adequate to the end. 

Subfig. 4 represents a form of twin teeth. The two must be 
extracted together, which may be difficult or the reverse, accord- 
ing to the character of the process. It is well, before making the 
effort to extract, to free the process from the teeth as thoroughly as 
possible: this is done by a sharp and flat elevator or the chisel. s 

Subfig. 5 represents a second form of twin growth, the result of 
original germ union. If the offshooting bulb is situated within 
and covered by the process, it is to be treated as if it were a case of 
exostosis of the fang. These germ unions are exceedingly rare, and 
one might not be met with in a lifetime. 

Among other curious examples of anomalous teeth to be seen in 
the Philadelphia Dental College are those exhibited on the succeed- 
ing page. Referring to the conjoined molars, the gentleman who 
presented the specimens remarks : 

" The practical feature in this case concerned the extraction. This 



THE EXTRACTION OF TEETH. 421 

was effected with less trouble than might be supposed. In the attempt 
to extract the second molar, it soon appeared that there was some- 
thing wrong, and the effort to remove it was suspended, and a 

Fig. 183. 





thorough examination made. In the second attempt, the force was 
very cautiously applied, to find what direction the tooth would 
take. It yielded most to an inward motion, and by a continued 
effort in that direction the removal was effected with only a slight 
fracture of the lingual border of the alveolus." 

The second specimen is a union of three of the anterior teeth. 



CHAPTER XVII. 

GENERAL REMARKS ON EXTRACTION. 

The relationship of the teeth with the jaws is through the medium 
of a cellular process known as the alveolar. Each tooth is lodged 
in pits or alveoli corresponding to the number and character of its 
roots: thus, the central and lateral incisors, the cuspidati, and the 
bicuspidati, having each but one root, have each but one alveolus. 

The molar teeth of the superior jaw have three roots, conse- 
quently a threefold relation to the alveolar process. 

The molar teeth of the inferior jaw have two roots and two al- 
veoli. 

The wisdom-teeth, as a rule, have a single short curved and 
stumpy root, consequently a similar alveolus. 

The association of the teeth with their alveoli is through the 
medium of a fibro-cellular tissue ; this membrane is coarse and resist- 
ing about the free edge of the bone, loose and cellular as it gets deeper. 
A properly-shaped lancet may be made to excise the coarse fibres; 
consequently, the operation of extraction should always be preceded 
by that of thorough lancing. In this way much of the strength of 
the relationship of the tooth with its socket is to be overcome. 

A tooth extracts with difficulty or with ease as influenced by the 
character of its periodonteum, and the loose or firm structure of its 
alveolus. 

A limited fracture of the alveolar process is generally not to be 
considered a matter of much consequence. If an extensive fracture 
should associate with an extraction, the tooth and bone may be laid 
carefully back in place, and treated as any common fracture ; or, if 
this does not seem desirable, the fractured piece may be dissected 
from the soft parts, and the wound treated on general principles. 
Sometimes, when too much force is injudiciously used, a fracture 
may occur, including several teeth. In such accident, the circum- 
stances of each particular case must direct the practitioner ; they are 
ugly and generally unnecessary troubles, and not apt to occur where 
proper care is exercised. Meeting myself with such an accident, I 
(422) 



GENERAL REMARKS ON EXTRACTION. 423 

should certainly make a first effort to reunite the parts ; failing in 
which, I would have, of course, no resource but to dissect away the 
piece, or otherwise wait on nature for a process of exfoliation. 

Laceration of the gums is an accident frequently associated with 
the careless extraction of teeth. Such laceration may be trifling or 
it may be serious, and is, perhaps, always to be guarded against by 
proper attention to lancing. A small piece of gum torn by a tooth 
as it comes away had better be removed ; left in the mouth, it is 
a source of annoyance, and reflects, in the mind of the patient, 
on the practitioner. Large strips are to be carefully laid back in 
place, and secured by one or more stitches, or other convenient 
means of retention. 

Hemorrhage. — Hemorrhage after extraction is influenced by two 
circumstances: the state of the parts, and the predisposition of the 
patient. An ordinary tooth extraction is followed by hemorrhage 
lasting but a very few minutes. In extraction for periodonteal trouble 
the bleeding is more profuse. Such hemorrhage, however, if at all 
reasonable, is not to be interfered with ; it expedites the cure of the 
case wonderfully, relieving the general congestion of the parts. 

Undue hemorrhage of local signification is found to depend either 
on non-contractility in the foraminal and circumferential vessels, or 
on excessive vascularity in the alveolar walls. Where the bleeding 
is from an artery, it will be more or less per saltern; where venous 
or capillary, it will be continuous. Hemorrhage of constitutional 
expression is associated with the defibrinating condition, or with 
hereditary predisposition. Anaemia as a cause is perhaps the most 
common of the systemic vices ; next to this may be ranked a typhoid 
state ; after this, purpura. Plethora conjoined with laxity of the 
tissues is another of the constitutional causes. Vicarious relation- 
ship is a condition sometimes met with. 

In cases where a hemorrhagic diathesis exists, alveolar hemor- 
rhage is not unfrequently of the most profuse character, making 
necessary the most judicious and energetic treatment for its arresta- 
tion. Two cases, occurring with the author in the persons of a 
father and son, may illustrate such direction of practice. 

Mr. B., aged 19, applied to his dentist for the removal of the 
second superior molar, of the right side. The operation over, the 
bleeding seemed not excessive, and the patient was dismissed as 
usual. On the same day, in the latter part of the afternoon, bleed- 
ing recommenced ; Monsel's solution of the persulphate of iron was 
employed, and the patient again dismissed. During the night hem- 



424 ORAL DISEASES AND SURGERY. 

orrhage again recurred, and the family physician was sent for; the 
solution of iron was again employed, and a temporary arrest again 
secured. The next day it reappeared, and nitrate of silver was 
applied in the alveolus. This controlled the hemorrhage until the 
succeeding day, when it again appeared ; and so off and on over a 
period of eight days. At this time I first saw the case in consulta- 
tion, the patient being unable to swallow any other than liquid food, 
owing to the swelling of the fauces and oesophagus from the effects 
of an over-free use of the nitrate of silver. 

In examining the case, we first took from the cavity the half- 
coagulated clot it contained, and, washing the parts thoroughly, 
discovered that the bleeding came not alone from the socket of the 
tooth, but from about the margins which had been ulcerated and 
degraded by the various applications. Hemorrhage was entirely 
capillary. 

In a treatment which resulted in the immediate control of this case, 
the following course was pursued. First, an impression in wax was 
taken of the roof of the mouth, inclusive of the bleeding part. From 
this impression a model was made, to which was struck a silver 
plate. This accomplished, which consumed about two hours, the 
bleeding cavity was packed with alum-saturated lint, the lint pro- 
jecting and overlying the ulcerated margin. Over and upon this 
was now placed the accurately fitting and compressing plate. Upon 
the plate, raised to the common level of the adjacent teeth, was laid 
a fold of linen : the lower jaw was next closed upon this compress 
and kept in position by a bandage. Tincture of Erigeron Canadensis 
was administered, and the feet of the patient were placed in hot water. 
Hemorrhage ceased entirely in the course of an hour, and did not recur. 

Mr. B., the father of this young gentleman, aged perhaps 50, suf- 
fered five days from hemorrhage, under the following circumstances : 
A wisdom-tooth of the left upper jaw troubling him because of its 
great looseness, he applied to his dentist for its removal. Not 
deeming it necessary or desirable to wound the gum, the practitioner 
extracted the tooth without the preliminary step of lancing, and in the 
act was so unfortunate as to tear away a small strip. Hemorrhage 
was immediate, and more or less continuous. Monsel's solution being 
prescribed by his physician, it was employed, but with somewhat 
the same result as in the son's case. On the evening of the fifth 
day I first saw this case. The patient was much weakened from 
the excessive discharge, and exceedingly frightened and nervous. 
Washing away the clots, I discovered the blood oozing* from the 



GENERAL REMARKS ON EXTRACTION. 425 

torn gum, and not at all from the tooth-socket. I commenced imme- 
diately to give erigeron in drop doses, repeated every minute, and 
ligatecl against the wound a tuft of alum-saturated cotton. The 
hemorrhage ceased entirely within ten minutes, and did not recur. 
As an assurance, I prescribed the wine of iron, which the patient 
continued to take to the amount of four ounces. 

Tincture of Erigeron Canadensis, in cases of this character, seems 
to be a quite reliable haemostatic; not entirely so, however, as I have 
prescribed it where it certainly failed to exert the slightest influence. 

Hemorrhage dependent on the typhoid condition is to be treated 
with most success by conjoining with the local medication the 
internal administration of acids, than which none seems to answer 
so good and reliable a purpose as the dilute hydrochloric. Purpura, 
as a predisposition, demands its own peculiar class of remedies. 
Anaemia is best treated for immediate ends with the tincture of 
the chloride of iron. Yicarious hemorrhage requires an attention 
which shall dispose to the restoration of the lost harmony. What- 
ever the systemic vice, appreciation of the requirements and the 
meeting of the indications constitute a most important direction in 
the treatment. 

Depressing the action of the heart is, under almost all circum- 
stances, a most valuable means for the arrestation of hemorrhage. 
To this end the tincture of veratrum viride is always to be given 
with satisfaction. Conjoined with this, and indeed in many instances 
quite capable of taking its place, is the hot foot-bath, — the impres- 
sion to be continued until the patient shall either grow faint or break 
out into profuse perspiration. 

Lead and opium prescribed in conjunction form a very reliable 
haemostatic ; two grains of the first to one of the latter may be given 
every two or four hours, according to the urgency of the case. 

Rest is one of the reliable means of cure. A patient is to be kept 
quiet, both as the body and the mind are concerned. 

The local treatment of dental hemorrhage has the threefold signifi- 
cation of mechanical, vital, and chemical. The first considers means 
which, through compression or clot, shall confine the blood to its 
vessels. Plugging the alveolus is a common practice in this direc- 
tion. A plug may be made of almost any convenient material ; 
common raw cotton, or shreds of lint made by scraping linen, 
answer commonly every purpose. When hemorrhage is per saltern, 
a splint of soft pine wood, shaved to a point corresponding with the 
apex of the alveolus, being carried and retained in place, will almost 



426 ORAL DISEASES AND SURGERY. 

of a certainty control the hemorrhage. Plates of metal or gutta- 
percha, moulded so as accurately to close the cavity, thus favoring 
the formation of a clot, are frequently employed with success. 
Spider-web as a clot-holder is another means, the web being packed 
into the cavity and there retained. Compressed sponge is still 
another of the mechanical means. This, when thoroughly coated 
w r ith wax and of delicate point, may be carried to the very apex of 
a cavity, and, when forced into itself and maintained in position by 
an overlying compress, constitutes one of the most reliable of this 
character of agents. 

Of the medicinal agents having the signification of forming a clot, 
preference is to be given to tannic acid. The persulphate of iron, a 
preparation much used in general practice, is to be denied applica- 
tion in the mouth. Without doubt a clot is to be formed more 
speedily and solidly with this agent than with the tannin, but the 
danger from secondary hemorrhage overbalances all its virtues. A 
tannin clot is not soluble by the blood, and needs but support to 
possess all required virtues. 

Of the astringents and stimulants, acting by exciting responsive 
force in the tissues to which they are applied, and controlling hem- 
orrhage through contractility, we have alum, zinc, lead, capsicum, 
iodine, turpentine, and most of the mineral acids. 

Alum in full saturation with water is one of the most reliable of 
the haemostatics, and, w r hen properly supported by a mechanical 
adjunct, it will seldom be found to fail. 

Of agents acting chemically to the control of hemorrhage, mention 
may be made of catechu and kino among the vegetables, and nitrate 
of silver among the metals ; the latter, however, is an objectionable 
preparation, because of the destruction of tissue so common to its 
employment, except when used in dilution. 

All ordinary means failing for the control of an alveolar hemor- 
rhage, the actual cautery may be applied. A control thus secured, 
however, is to be seconded by the anti-hemorrhagics of internal 
expression, as it is frequently found to be the case that the separation 
of the slough re-excites the original trouble. 

Compression made to a bleeding alveolus should be moderate, 
not severe ; and when made, and the hemorrhage has been con- 
trolled thereby, it should not be too ( hastily removed. 

Luxation of the Inferior Maxilla. — Occasionally, as the 
result of a sudden movement, or an abnormal laxity of the ligaments 
of the temporo-m axillary articulation, the condyloid process falls 



GENERAL REMARKS ON EXTRACTION. 427 

forward over its glenoid boundary. The patient is thus rendered 
unable to close the mouth, and is said to labor under luxation. (See 
chapter on Luxation.) 

Local Anesthetics in the Extraction of Teeth. — The em- 
ployment of various local agents to secure exemption from pain in 
the operation of extraction has of late commanded so much atten- 
tion that no chapter treating of such operations would be complete 
without reference to the subject. 

The most simple and, we may say, elementary application in this 
direction consists in inclosing in a piece of bladder, or other conve- 
nient skin, a small portion of pounded ice and salt, and enveloping, 
for a few moments, the part to be operated on. To secure most 
conveniently the effect of such a process of refrigeration, various 
instruments have been devised, but none, so far as the application 
of the ice and salt is concerned, have been found to answer any 
better purpose than the bladder or skin inclosure. Such skins 
should consist of two little bags, one to rest upon the outer, the 
other upon the inner, side of the gum. To prevent pain from the 
application of the cold, the bags should be brought gradually in 
contact with the gums ; or, what will answer a similar purpose, the 
application may be preceded by ice-cold water held in the mouth for 
a few moments. 

An apparatus designed and manufactured by Messrs. Home & 
Thornwaite, of London, is said to answer a very good purpose, and 
is thus described : 

"A required amount of water is cooled down, by means of ice and 
salt, to about zero, in a vessel called a refrigerator. To this vessel 
is attached another, called a graduator, containing warm water at 
about 100°, and so constructed as to allow the slow admixture of its 
contents with the chilled water in the refrigerator, and thus produce 
a gradually diminishing temperature, for the purpose of preventing 
sudden shock and pain to the teeth, which a direct application of 
cold would inevitably cause. A tube conveys this graduated cur- 
rent into a terminal portion constructed of very fine membrane, 
which adapts itself to the form of the gums, and wholly surrounds 
the tooth to be extracted. The fluid then passes away through an 
exit tube. In this manner a constant current of cold, at a decreasing 
temperature, is made to pass over the part, abstracting therefrom 
all heat, and consequently all feeling." 

The concentrated tincture of aconite is a useful local aneesthetic, 
but one that should be used with a considerable degree of caution. 



428 ORAL DISEASES AND SURGERY. 

If a portion of this tincture be applied to one-half the lip, sensibility 
will be so interfered with that a goblet placed to the parts will 
appear as if broken. 

A mixture of chloroform and laudanum in equal parts is much 
lauded by some. To apply this, it is only necessary to saturate a 
tuft of cotton and lay it against the tooth to be extracted. 

Another means, serving to attract the attention of the patient 
from the operation, consists in painting the gum heavily with tinc- 
ture of iodine. After such painting, people will often be found to 
say that the pain has been much ameliorated. 

Electro-galvanism claimed at one time a good share of attention. 
Its application consists in applying one pole of a battery to the for- 
ceps, while the other is held in the hand of the patient; a gentle 
current is then to be let on, during the passage of which the tooth 
is extracted. This mode of effecting local anaesthesia is still prac- 
ticed by very many; but I must say that, in my hands and in the 
hands of many experienced friends, it has proved a failure. Not 
that it is to be denied that in certain cases it does seem somewhat 
to obtund sensibility, but in the majority of instances it either does 
no good at all, or adds the discomfort of the current to the pain 
of the operation. 

The application of the spray of ether or of rhigolene is the latest, 
and perhaps the most worthy and reliable, of the local anaesthetics ; 
certainly one may say reliable when employed for operations of 
limited extent about the soft parts, but as to an equal availability 
in tooth extraction, my experience has not so well satisfied me. 
With these agents as thus locally applied I have performed many 
incisions, in the way of the removal of sebaceous and other super- 
ficial tumors, the opening of abscesses, carbuncles, and similar 
operations, and the result has been everything I could have desired ; 
but in their application to the teeth, the obtunding of the sensibility 
has not by any means been so marked ; and particularly has this 
been the case where rhigolene was used. 

The process of freezing a part through the known refrigerant 
power of evaporating ether seems first to have suggested itself to 
Dr. Richardson, of London. An instrument invented by this gentle- 
man for the accomplishment of such an end is here exhibited, forms 
of bellows for both hand and foot being represented. 

For the spraying of any plain surface, the simple straight tube is 
all that is necessary. For the teeth, the double sprayer, as seen in 
the drawing, is used ; with this instrument a continuous vapor is 



GENERAL REMARKS ON EXTRACTION 



429 



cast both upon the outer and the inner face of the gum, and congela- 
tion is rapidly induced. 

Fig. 184. — Spray Apparatus — Hand-Instrument. 




In using this hand-instrument, the operator himself should not 
work the pump. A very few moments' compression of the ball 
renders the hand shaky and unmanageable. 

Upon this instrument of Dr. Richardson's many modifications 
have already been made. Of these, one by Messrs. Codman and 
Shurtleff, of Boston, has perhaps attracted, most attention. It cer- 
tainly seems to divide the ether more infinitesiroally, thus insuring 
a more complete vaporization ; but it has a weak point, in that the 
tube seems frequently to freeze or choke up, an accident that does 
not occur with Dr. Richardson's instrument. 



An objection urged to the use of extreme cold as thus induced is 
that injury is done to the soft parts, as it is thought will be mani- 
fested in inability to unite wounds happily and easily. That such 
objection is, however, not valid, I have satisfactorily proven ; for, if 
anything, parts thus operated on have united better and with less 
inflammatory reaction than has obtained where the spray has not 
been used. 



430 



ORAL DISEASES AND SURGERY. 



Rhigolene or hydrocarbon, manufactured from coal-oil, and much 
vaunted by some, has not, in my hands, proven so satisfactory as 



Fig. 185. — Spray Apparatus — Foot-Instrument. 

w 




ether. It certainly freezes a part more quickly than this latter 
agent, but this does not seem alone to be the object, as anaesthesia 
is not nearly so complete. 



CHAPTER XVIII. 



GENERAL ANESTHESIA. 



" So long as pain is an evil and ease a good — so long, in other 
words, as man is man — must any means be prized that is capable 
of achieving the latter by the abolition of the former. As, then, the 
pain of surgical operations is certainly of the most terrible of its 
class, and it is no matter of doubt that agents exist which possess 
the power of abolishing this pain, what remains for consideration 
is not so much whether this means shall be hailed as a matchless 
and priceless discovery, and be cherished and adopted as a blessed 
thing, — this appreciation has been made, this adoption has been 
consecrated by almost universal practice : what remains for con- 
sideration is, whether the good is a pure good, or is counterbalanced 
by evil. 

11 The obvious, open, palpable, glorious good of anaesthesia, and 
particularly ether anaesthesia, is to deliver the wretched victim of 
surgical disease from the additional torture of pain while seeking 
the goal of health through the portals of chirurgery. The evils 
that have been said to follow or accompany this good have, how- 
ever, been regarded by some as of so serious a character as not only 
to induce them to reject general anaesthesia in their own practice, 
but to denounce it publicly as a means that should not obtain with 
scientific and conscientious men. 

''We confess that we are surprised whenever we hear these 
expressions ; and, strange as it may seem, there are even now 
enough to give expression to them. Of the hundreds and thousands 
— we might say hundreds of thousands — who have taken ether to 
insensibility, we have been unable to discover, after the most ex- 
tended inquiries, a single case which resulted in death, or left behind 
it consequences of serious importance that were certainly attributable 
to it. In a small proportion of cases there have, no doubt, been 
some unpleasant results, such as temporary depression of the vital 
powers ; headache, more or less considerable, for some hours, or 
even days ; hysterical excitement in women for a similar length of 

(431) " 



432 ORAL DISEASES AND SURGERY. 

time ; slight bronchial irritation, nausea, and sickness, and some 
other slight affections ; but the proportion of patients suffering, 
even in this slight manner, has been extremely small, — indeed, won- 
derfully small, when we consider the indiscriminate manner in which 
the practice has been had recourse to, with bad ether and bad 
manipulators. Indeed, that so very few and such trifling accidents 
have occurred in such a state of things, is most convincing proof of 
the general safety of the practice. For, in considering the entire 
incompetence of the many who are in daily, fearless employment of 
the agent, so far from these uniformly innocent results being antici- 
pated, one might very naturally look for others of a very different 
kind. "We have ourselves been constantly looking for ill conse- 
quences, and we are still prepared to find them; but when thy 
arrive, if ever they now are to arrive, we shall have to consider 
well, before condemning the agent, whether the event was a neces- 
sary consequence of its use, or merely an accidental result from its 
abuse." 

The preceding very impartial and terse consideration of the gen- 
eral question of anaesthesia, as reference is had to its production by 
sulphuric ether, we find in a British monograph. The question, " To 
what are accidents (if accidents there are) attributable ?"is naturally 
suggested, and would excite in the mind a desire to enter on the 
consideration of a subject fraught with such importance, before 
taking up its use or joining in the cry of those who abuse. 

Such consideration I propose to make the subject of this chapter, 
and trust that not a little personal experience enjoyed will enable 
me to present it with some degree of clearness. We first consider 
sulphuric ether. 

An agent, refreshing in itself, may, in improper hands, become a 
source of ill : this truth applies to the whole Materia Medica. 

What is sulphuric ether ? 

"When equal weights of rectified spirits and oil of vitriol are 
mixed in a retort, the latter connected with a good condensing 
arrangement, and the liquid heated to ebullition, a colorless and 
highly-volatile liquid, long known under the name of ether, or 
sulphuric ether, distills over. The process must be stopped as soon 
as the contents of the retort blacken and froth, otherwise the product 
will be contaminated with other substances which then make their 
appearance. The ether obtained may be mixed with a little caustic 
potash, and redistilled by a very gentle heat. 

" Pure ether is a colorless, transparent, fragrant liquid, very thin 



GENERAL ANAESTHESIA. 433 

and mobiJe. Its specific gravity at 60° is about ?20 ; it boils at 96° 
under the pressure of the atmosphere, and bears, without freezing, 
the severest cold. When dropped on the hand, it occasions a sharp 
sensation of cold, from its rapid volatilization. Ether is very com- 
bustible ; it burns with a white flame, generating water and carbonic 
acid. Although the substance is among the lightest of liquids, its 
vapor is very heavy, having a density of 2.586. Mixed with oxygen 
gas and fired by the electric spark, or otherwise, it explodes with 
the utmost violence. Preserved in an imperfectly-stopped vessel, 
ether absorbs oxygen and becomes acid, from the production of 
acetic acid. This attraction for oxygen is increased by elevation of 
temperature." (Fownes.) 

Dr. Jackson's formula for the preparation of ether for anaesthetic 
purposes is, we believe, as follows : procuring the strongest and 
purest rectified sulphuric ether, — that just described, — wash it well, 
to get clear of any acids ; then decant from the water, drying it 
with chloride of calcium, to free it of any water that might other- 
wise remain from the washing. 

This, however, is but a single formula. Different chemists arrive 
at the same ends through different processes. The surgeon should 
buy of a reliable druggist rather than attempt the preparation for 
himself. 

This, then, is ether, an agent which, as experience demonstrates, 
will produce insensibility when breathed into the lungs. To exhibit 
ether successfully, four essentials seem necessary: 

1st. That the ether should be very pure. 

2d. That the vehicle upon which, or with which, the agent is 
exhibited, should be of such character that full volume of atmo- 
spheric air is allowed to pass through the ether into the lungs. 

3d. That the vapor of the ether be properly diluted, given for the 
first few inspirations comparatively weak, and increased in strength 
as the glottis, air-passages, and lungs can bear it. 

4th. That insensibility be produced as quickly as the system will 
bear, as evinced by obvious signs. 

A cone-shaped, close sponge is the best means for administering 
ether. This possesses every advantage, except that of economy in 
the administration, without having any of the common faults. From 
two to five minutes will be found the average time necessary to pro- 
duce the full effect of perfect sleep ; though cases will present them- 
selves where double this time will be required, and where, indeed, 
it may be necessary to combine with the ether the more powerful 



434 ORAL DISEASES AND SURGERY. 

effect of chloroform, or even to employ the undiluted chloroform. 
From an article emanating from a gentleman of much experience in 
anaesthetic agents, we take the following suggestive remarks: 

"It is possible to inspire three, four, nay, ten times the quantity 
of ether capable of producing sleep, without this state being pro- 
duced, provided the vapor be taken in a too diluted form ; and we 
believe this over-dilution and its consequent protracted inhalation is 
a frequent cause of the excitement which supervenes in the practice 
of many persons, while it so rarely shows itself in that of others. 
In these cases the patient may be made drunk ; drunk in the first 
degree, but not dead -drunk, the condition required for surgical 
purposes." 

It will be remarked, let it be noticed in passing, that one of the 
most common objections of the opponents of ether lies at this door, 
— this supervening state of excitement instead of the desired state of 
stupor; but does not the question again very pertinently apply, Is 
the fault with the agent, or with the operator ? 

The idea is to be conveyed that the effects of sulphuric ether and 
of the common alcoholic beverages are the same. The effects of alco- 
holic liquids are too well known to require minute description. We 
have, first, the state of exhilaration, which gradually changes to com- 
plete stupefaction or narcotism : the last state, the result probably 
of a narcotized condition of the brain. Just so acts ether, yet passing 
through its various stages more quickly, the result of its being 
poured in a continuous and undiluted stream upon the heart and 
brain. The ether is no sooner absorbed than the blood charged with 
it passes to the left side of the heart, and immediately thereafter is 
circulated through the coronary vessels, the carotid and vertebral 
arteries, and thus pervades the tissue of all parts of the heart, as 
well as of every portion of the brain. A writer, in an influential 
dissertation, presents an example in this wise: 

" Suppose, to take an extreme illustration, that the blood was as 
capable of absorbing as much ether as water can combine with, or 
one-tenth its own weight. If, then, we suppose the blood in the 
lungs was impregnated to this extent, it would be applied in that 
state to the heart and brain ; whereas, if the blood in the stomachic 
vessels was impregnated to the same extent with ether, before reach- 
ing the liver it would have mingled with more than its own mass 
of pure blood from the splenic and mesenteric veins. The tenth 
would then become a twentieth, and, on the blood leaving the liver 
and joining the larger current of the inferior cava, the twentieth 



GENERAL ANAESTHESIA. 435 

would become a fiftieth or sixtieth; a further dilution would take 
place at the confluence with the superior cava, so that the blood, on 
reaching the heart and brain, instead of containing one-tenth part of 
absorbed ether, could not contain as much as one-hundredth. When, 
therefore, the same quantity of ether, or any absorbable substance, 
is taken up from the lungs and from the stomach, it must, in the 
former case, be applied to the tissue of the heart and brain in a state 
of concentration at least ten times greater than the latter, and will 
therefore act on these organs with more suddenness and energy." 

The evanescence of the effect of ether, as compared with that of 
alcohol, is explained by a momentary consideration of the different 
manner of absorption. During the inhalation of ether, as we have just 
seen, the charged blood is applied to the heart and brain, while the 
blood circulating in the lower parts of the body contains a much 
smaller proportion of it. Now, on stopping the inhalation, the blood 
in the heart and brain speedily passes off by the veins, and is suc- 
ceeded by the comparatively pure blood coming from the lower 
regions of the body, and so the narcotic symptoms disappear. 

" It is far otherwise when alcohol is absorbed from the stomach, 
for the whole mass of blood must be impregnated with it before a 
highly-charged blood can be applied to the heart and brain ; and 
then the effect continues for many hours, till the alcohol has been 
thrown out of the system by the lungs and skin. With respect to 
ether, it must not be supposed that on the subsidence of the nar- 
cotism it disappears from the body ; for it is merely weakened in its 
effects by being diffused over the whole mass of blood. This is 
obvious, from the smell of the breath for many hours, and from its 
frequently causing copious perspiration." 

Does not the question here suggest itself, If the effects of ether 
and of the common alcoholic beverages are so nearly alike, why the 
great dread of the one and the entire fearlessness with the other ? 
Would not the answer seem to be something of this kind ? Men 
when etherized are as dead-drunk : our eyes are accustomed to 
seeing them only partly drunk. In this state they excite amuse- 
ment : in the state of profound drunkenness they have always 
aroused our fears for their recovery. Associations have great 
weight. 

The immediate and obvious effects of etherization on the individ- 
ual hardly require notice, as they must be familiar to all our readers, 
if not from a personal experience, certainly from observation upon 
others. " All the usual phenomena of the deepest sleep supervene, 



436 ORAL DISEASES AND SURGERY. 

gliding often into the profoundness of sopor, and verging occasion- 
ally upon, if not actually lapsing into, coma. The voluntary mus- 
cles become suddenly relaxed, the jaw falls, the arms hang down, 
the eyes roll upward under the lid, the respiration becomes slow and 
labored, and the face becomes either very pale or morbidly flushed ; 
the aspect of things is truly such as can hardly be contemplated for 
the first time without alarm: the individual seeming, to the com- 
mon eye, to be sinking into the sleep of death." 

It is impossible, says another observer, to see a single case of ether- 
ization without being struck with its resemblance to asphyxia ; and 
experiments exhibit a real relation between the two. But in ordinary 
asphyxia the nervous system loses its power under the influence of 
black blood, or blood deprived of its oxygen. But in etherization it 
does so under the direction of this singular agent. This is really 
all the difference, for in both there is the same loss of sensation and 
voluntary motion, and the same at least temporary persistence of 
the respiratory movements. In one word, there is the same survival 
of the medulla oblongata over the spinalis. 

11 Etherization exhibits to us the entire mechanism of asphyxia : we 
mean the successive deaths of the various nervous centres. It iso- 
lates, just as mechanical experiments do, the intellectual powers, 
the co-ordination of the movements, sensibility, motility, life. The 
isolation of life — this point, this vital knot of the nervous system — 
forms the most striking point of the experiments. 

"' In an etherized animal one point alone survives, and while it does 
so. all others retain at least a latent life, and may resume their active 
life; this point once dying, all dies." 

Throwing out of immediate consideration the idiosyncrasies, let 
us for a few moments consider the question of the general safe ex- 
hibition of the agent, 

The safest agent may be made a source of ill : as the intruder on 
the physical laws of his organism must suffer the consequences of 
his ignorance or temerity, so may any agent, however good, be made 
an injury by its abuse. As the imbibition of alcoholic beverages may 
be carried to a point beyond which the life-principle reacts not, just 
so, and as the warmest supporters of the anaesthetics would have 
impressed, may ether be made an instrument of irreparable injury, 
blasting and destroying where it was designed to refresh and save. 

To lay down certain reliable rules, applicable in all cases, for the 
process of etherization, is an impossibility. The presentments of 
conditions in various individuals differ so material] v, that it would 



GENERAL ANESTHESIA. 437 

be charlatanism to act upon any but rules resulting in a general 
knowledge of the agent and a comprehension of physiological laws 
and pathological alternations. One person, as Dr. Snow remarks, 
" shall become impassable as the subject on the dissecting-table ; 
another talks incoherently or mirthfully, replies to questions, or 
obeys directions; others utter exclamations of pain, which they 
afterward retain no reminiscence of having felt; and others again 
declare that they have suffered pain but felt themselves powerless 
for its expression. Finally, in not a few, ungovernable violent or 
convulsive action takes place, quite adverse to the performance of 
any delicate surgical operation. With some an utter oblivion is 
induced ; w T hile others, while undergoing all the apparent torture of 
a prolonged dissection, are reveling in the realms of memory and in 
the fields of imagination." M. Jobart and other observers have 
attempted to lay down three distinct stages in the effects of the agent, 
according to the prolongation of the etherization. 1. That of inco- 
herence, agitation, or delirium, as the case may be. 2. Acceleration 
of the pulse, with loss of sensibility and loss of power. 3. Exhaustion 
and coldness of the surface. As we have remarked, the matter cannot 
thus be methodically laid down, for it is quite certain that any of 
these conditions may be induced, in different individuals, by very 
various doses of ether ; while others, again, are susceptible of only 
the first degrees, to appearances, and yet enjoy an immunity from 
suffering during operations. Even the quickened condition of the 
pulse and respiration, and that almost universally employed crite- 
rion, the stationary condition of the pupil, may deceive in the 
supposed impression produced. 

A number of the French Academicians some years back instituted 
a series of experiments upon animals, for the purpose of determining 
the mode and order in which the various portions of the cerebro- 
spinal system were influenced during inhalation. The following are 
some of the conclusions arrived at by the veteran vivisector, Baron 
Flourens : 

" The action of ether upon the nervous centres follow r s in a given 
course. It acts, first, upon the cerebral lobes, disturbing the intellect. 
It acts, secondly, upon the cerebellum, deranging the equilibrium of 
the movements of the animal. Thirdly, it acts upon the medulla 
spinalis, in which it extinguishes, successively, the sensory and 
motor principles: and, lastly, it acts upon the medulla oblongata, 
where arrived, life becomes extinct." 

To produce the best effects of sulphuric ether, it is of the first 



438 ORAL DISEASES AND SURGERY. 

consequence that an entirely reliable article be employed. " For 
myself," says Dr. Robinson, of London, "I feel convinced that many 
of the failures that have occurred in its administration in some 
measure may be attributed to the imperfect preparation of the fluid. 
I have myself obtained ether of various specific qualities from dif- 
ferent chemists; and on one occasion, requiring an extra quality for 
a series of experiments, the gentleman supplying, being out of that 
quality he had generally furnished, sent some of a different kind 
which he had in his establishment, which was administered in 
two cases. I found, however, I could only produce partial uncon- 
sciousness, not insensibility to pain, and therefore deferred the 
operations, which were upon the teeth. I afterward procured some 
of the first quality ether, and employed it in the same case with 
success." 

The effect of a bad article of ether is not only the inability on the 
part of the operator to produce more than a partial unconsciousness, 
but it is almost certain to produce nausea, giddiness, and prostra- 
tion. If a good article cannot be procured, better use none at all. 

The quantity of ether that may be given to any individual patient 
is a matter for the practitioner to decide upon in connection with 
each case. It is impossible to fix the dose of vapor that will be 
required to produce given effects upon any patient, neither is it 
always an easy matter to decide when just enough has been admin- 
istered. We cannot rely implicitly on the state of the pupil or pulse, 
or upon what is considered by so many as an exact indication, — 
namely, the insusceptibility of the eyelids to impressions made by 
striking the hairs. Perhaps the changes in the breathing are the 
most reliable signs: these certainly influence me most; so long as 
breathing continues easy and natural, little danger is to be antici- 
pated, but the moment it becomes labored, one is to proceed or 
recede cautiously. In etherizing a patient, let the operator watch 
the pulse, the expression, and the respiration. So long as these 
give no counter-indications, the exhibition may be carried forward 
to the end desired. 

As to the question of the continuance of a patient in the anaesthetic 
condition, I think it will be found the proper rule to make the time 
just as short as possible ; that is to say, as the continuance of the 
exhibition of the agent is concerned. If an operation to be per- 
formed in the anaesthetic condition may be completed in five, ten, or 
fifteen minutes, it is not good policy to prolong it, and with it the 
continued administration of the ether, to a half or a full hour. That 



GENERAL ANAESTHESIA. 439 

there is, however, any imperative or absolute necessity to hurry 
through an ether case is not at all implied. I have known a patient 
kept continuously under ether for forty-two hours ; and in obstet- 
rical practice ten or twelve hours of anaesthesia is not at all unfre- 
quent. I only contend that it is neither necessary nor prudent to 
prolong, without object, the condition. Where, however, such a 
prolonged action is demanded, it is to be secured, not by keeping the 
saturated sponge constantly applied over the air-passages, but by 
applying- it at such intervening periods as may be necessary to pre- 
serve the anaesthesia. 

The condition of the temperature, as might be inferred, has much 
to do with prolonging or shortening the time commonly considered 
necessary to place a patient in a state of sleep. . Dr. Snow obtained, 
from experiments, the following results: 

One hundred cubic inches of air, saturated with the vapor of 
ether, at a temperature of 

44° would contain 2T cubic inches of vapor. 
54° " 24.3 

64° " 43.3 

74° " 53.6 

84° " 66.6 

Being doubled by a rise of only thirty degrees ; or, in other words, 
if at a temperature of 84° Fahrenheit we employ two or two and 
a half minutes in affecting a person to the state desired, at a tem- 
perature thirty degrees lower we would require from four and a half 
to six minutes to obtain the same result. 

Concerning the idiosyncrasies, I would speak my own experience 
by saying that I have never yet met with a person who I thought 
might not take ether, or ether in combination with chloroform. The 
London Medical Gazette considers its use inadmissible where there 
is a tendency to apoplexy or epilepsy, and also in plethoric individuals. 
Another intelligent source says that persons presenting the slightest 
signs of being cataleptic should be viewed as idiocratical. Persons 
under the influence of liquor, it is generally considered, should be 
viewed for the time as not fit subjects. 

In a conversation with Dr. J. B. F. Flagg, had several years back, 
that experienced man told me that he believed in no idiosyncra- 
sies, except it might be a very high, nervous temperament; that 
he had administered ether to the infant of thirty-six hours and to 
persons in extreme old age ; had given it to the robust and the 
weak, the plethoric and the consumptive; had used it in all stages 



440 ORAL DISEASES AND SURGERY. 

of pregnancy, except that stage known as quickening ; would also 
exhibit it here, but would feel called on to exercise more than ordi- 
nary care. Seeming idiosyncrasies might generally, he thought, 
be explained by an examination of the operator's ignorance of the 
agent. The faith of this gentleman in the perfect safety of the use 
of ether was so great that he remarked he would not hesitate to use it 
where there had been, or was, aneurism of the aorta. The opinion 
of Dr. Flagg concerning the non-existence of idiosyncrasies is to be 
taken before that of most persons, either of this country or Europe. 
His opportunities for observation were not surpassed by those of 
any other person, and perhaps equaled by few. A work published 
by him in 1854, long before his retirement from practice, has not, 
up to the present day, been advanced on, and is an heirloom to be 
valued by those to whom his industry has left it. 



CHAPTER XIX. 



GENERAL ANAESTHESIA. 



From the consideration of sulphuric ether we may pass to an 
investigation of the character and merits of the perchloride of 
forinyle, or chloroform. This agent is, without doubt, the most 
powerful and reliable of the anaesthetics ; but, unfortunately, it pos- 
sesses qualities which render it not unfrequently fatal to life, and 
therefore make it of less value than the one we have just been con- 
sidering. No person should employ chloroform who is not prepared 
to meet many emergencies. 

To procure chloroform, the chemist takes of chlorinated lime say 
(to take a common formula), lb. iv ; rectified spirits, ss ; water, x ; 
chloride of calcium, broken in pieces, 5j- Put the lime, first mixed 
with water, into a retort, and add the spirits, so that the mixture 
may fill only the third part of the retort. Then heat them in a sand- 
bath, and as soon as ebullition begins withdraw the heat as quickly 
as possible, lest the retort should be broken by the sudden increase 
of heat. Let the liquor distill into the receiver so long as there is 
nothing which subsides, the heat being reapplied if necessary. To 
the distilled liquid add a quarter of the water, and shake them all 
well together. Carefully separate the heavier portion, which sub- 
sides, and add the chloride to it, and frequently shake them for an 
hour. Lastly, let the liquid distill again from a glass retort into a 
glass receiver. 

In appearance, chloroform resembles the freshest water of the 
mountain-spring. To the taste it is hot and very sweet; to the 
nostril it has much the odor of the common strawberry. When 
dropped upon linen it evaporates very quickly, leaving, if pure, no 
stain or sign behind. In weight it is quite one-half heavier than 
water, and, as its vapor is concerned, is four times heavier than 
atmospheric air. 

The smell of chloroform, says Dr. Snow, should be esteemed one 
of the best tests of its purity and identity. When dropped on the 

(441) 



442 ORAL DISEASES AND SURGERY. 

hand it should quickly evaporate, leaving not the least smell or 
moisture behind. If a disagreeable odor remains on the hand after 
the evaporation, the chloroform has probably been made from impure 
spirits, or even from wood or acetone, and is therefore unfit for me- 
dicinal purposes. When chloroform becomes decomposed from any 
cause, it acquires a greenish-yellow color, and gives off chlorine and 
hydrochloric acid, so that the alteration is at once apparent. When 
chloroform is pure, it has no reaction on test-paper, but is quite 
neutral. The best way, according to Dr. Snow, to detect a small 
quantity of hydrochloric acid in it, is to moisten a slip of blue litmus 
paper with distilled water, and hold it just within the neck of the 
bottle exposed to the vapor. If sulphuric acid be present, it may 
be discovered by agitating the chloroform with distilled water and 
adding nitrate of baryta. 

Chloroform may be degraded by admixture with alcohol, and this 
can be done without making any perceptible change in its appear- 
ance : its specific gravity, however, is thereby lowered ; and, accord- 
ing to M. Mialhe, the foreign presence is most easily detected by 
adding to the suspected fluid a small quantity of water, when a 
milky opacity results. 

Chloroform, as the heart's action is concerned, is a powerful seda- 
tive. In nearly if not quite all the fatal cases resulting from the 
administration of this agent, cardiac syncope has been the cause of 
death ; and in a very small minority of the cases indeed has there 
been any evident interference with the process of respiration. This 
fact is always to be held in strictest remembrance when exhibiting 
the agent. 

In oral surgery, where it is desirable to produce the profoundest 
and most prolonged primary impression, chloroform, if it were 
without danger, is the anaesthetic most indicated and required. In- 
deed, in my own practice I find many cases where I do not seem 
to be able to get along without it, using it either alone or in associa- 
tion with the ether. Therefore, because its use is so frequently 
necessary, the oral surgeon should make himself as familiar as pos- 
sible with all that concerns its defects as well as its virtues. 

Experiments have demonstrated that eighteen minims of chloro- 
form is the average quantity necessary to put an adult in a con- 
dition of insensibility to surgical operations, — that is to say, that 
this amount should be absorbed and carried to the nerve-centres. 

It has also been shown " that chloroform vapor has the effect of 
suddenly arresting the action of the heart, when it is mixed with 



GENERAL ANAESTHESIA. 443 

the respired air to the extent of eight or ten per cent, or upward." 
With these two lessons appreciated, it is seen that the manner and 
character of the exhibition of the agent have much to do with 
the result. Not everything, however, as it is undeniable that fatal 
accidents have occurred in the best and most skillful hands, although 
in these latter cases the inference is to be drawn that the deaths 
occurred from idiosyncrasies. 

Eighteen minims, according to Dr. Snow, are to be absorbed from 
thirty-six breathed ; allowing thus that one-half is lost in expiration. 
But temperature, as in the case of the ether, has much to do with 
the taking up of such a quantity. The following table comprises 
the experiments of Dr. Snow in this direction. At a temperature 
of 40° Fahrenheit, one hundred cubic inches of air will take up but 
seven cubic inches of the vapor. 



At 45° 


8 cu 


ibic 


: inches. 


At 70° 


24 cubic inches. 


50° 


9 




a 




T5° 


29 


n 


55° 


11 




a 




80° 


36 


a 


60° 


14 




" 




85° 


44 


a 


65° 


19 




(i 




90° 


55 


a 



This table readily exhibits the fact that anaesthesia by the use of 
chloroform must come on at varying periods, and that therefore no 
judgment of its proper exhibition is to be derived in this direction. 
Again, outside of these atmospheric associations, the manner of 
the exhibition would have much to do with the minims inspired : 
where, for example, it is exhibited poured over a single layer of 
linen (as upon a handkerchief laid over the face), quite as much 
would be lost in the surrounding atmosphere as would be inhaled 
into the lungs. 

Considering the danger as arising from the direction of cardiac 
syncope, advantage is to be taken of all conditions antagonistic to 
such depression. In bloodletting, it is known that such a condition 
is much the most readily brought about when the operation is per- 
formed on the patient standing, and when the primary impression 
is made most marked through a large exit for the blood. In states 
of depression, arising from whatever cause, either of physical or 
mental disturbance, such tendency is increased. A surgeon always 
hesitates to bleed a depressed patient; or, if such bleeding seems a 
necessity, supporting means are employed and continued in con- 
junction with the bloodletting. Advantage is taken also of all col- 
lateral indications, as, for example, position, the patient lying down, 



444 ORAL DISEASES AND SURGERY. 

the head perhaps being placed on a lower plane than the body, the 
orifice of exit being made very small, intermissions in the flow of 
the blood, stimulants, as the pre-exhibition of brandy or wine, kind 
and encouraging assurances, etc. The depressing effect of fear on 
the heart's action is never to be lost sight of in the administration 
of chloroform. How many patients faint even while preliminary 
arrangements in anticipation of an operation are going forward ! 
and, indeed, how many are the cases on record of death from such 
fright! It would seem, then, that one would never be justified in 
administering chloroform to a patient laboring under any marked 
depression ; at least such is my own conviction, and upon such con- 
viction I have always acted. All persons, or nearly all, approach 
an operation with a certain amount of trepidation ; but such fear may, 
in the majority of cases, be dispelled ; or if this is impossible, then 
a preliminary artificial courage may be given by the use of brandy, 
or cerebral consciousness may be disturbed by the inhalation of a 
few drachms of ether. 

The objection that chloroform should not be administered to a 
patient in a sitting position does not, however, seem to hold entirely 
good. In oral surgery this is nearly always the necessary position ; 
and I have thus administered it, in perhaps hundreds of cases, with- 
out ever having had any ill result. A difference in the character 
of cardiac syncope is here to be recognized. The paralysis may 
arise from two sources, and exhibit, as the state of the heart is con- 
cerned, quite different appearances ; that is, there is a syncope of 
anaemia and a syncope of narcotism. Now, while there is between 
these two conditions much relationship, as the question of a vital 
propulsive force is concerned, yet there are also certain differences, 
of which, as surgeons, we may take advantage. Paralysis of the 
heart occurs when, from any reason, the organ is deprived of the 
effect of its natural stimulus, the blood : this is the syncope or paral- 
ysis of anaemia. It occurs again when, through the action of a 
common or specific narcotic, its muscular fibres are relaxed and 
deadened. The two causes may exist and act in conjunction. 
Chloroform is a specific narcotic, as the heart is concerned ; at least 
this would seem to be the deduction from post-mortems made in the 
fatal cases of its exhibition. In anaemia, syncope is partly a me- 
chanical production ; the patient, in a standing position, faints, as 
the result of gravity counterbalancing the natural distribution of 
the blood. In narcotic syncope, position is, perhaps, of little con- 
sequence, at least as the action of the producing cause is, of itself, 



GENERAL ANESTHESIA. 445 

concerned. The question, then, of sitting or lying, as the exhi- 
bition is concerned, resolves itself into a consideration of the state 
of the general health of a patient : if there is deficiency either in 
quality or amount of the vital fluid, then the erect or even semi- 
erect position should never obtain. If, on the contrary, a patient 
does not present such conditions, then it would seem there is no 
special danger in such position. 

Prefatory stimulation, if not contra-indicated, is happily employed 
in conjunction with chloroform. A tablespoonful or more of brandy 
given to a patient some five or ten minutes before the exhibition of 
chloroform, will frequently support the natural action of the heart 
through a prolonged operation, and thus dismiss the common source 
of alarm. 

In my own practice I never like to use chloroform but in conjunc- 
tion with ether ; not mixing them, as in the common chloric ether, but 
alternating, as the case seems to require or allow. Thus, employing 
the cone of sponge, I commence the process by pouring within it a 
quantity of ether, when it is gradually, and yet as rapidly as possible, 
brought to cover the mouth and nostrils. If now I find the pulse 
rapidly increasing, or even remaining fixed and steady, and par- 
ticularly if undue cerebral excitability manifests itself, I drop into 
the cone ten or twenty drops of chloroform. This will generally be 
found to quiet the patient almost instantly. From this point I pro- 
ceed, using principally the chloroform or ether, according to the 
result to be secured. If an operation is one of simple character and 
of quick performance, as the extraction of teeth, or the making of 
some simple puncture or incision, then I think we had better not 
risk anything with chloroform. If, on the contrary, it is some diffi- 
cult and tedious case about the mouth, where, after commencing, the 
surgeon cannot well stop to readminister the anaesthetic, then I take 
the risk of the excess of chloroform for the prolonged effect it yields 
and the greater profundity of the impression it secures. 

The manner of the exhibition of the agent would have, as one 
would infer, much influence, as the result is concerned. Thus, of 
the various apparatuses that have from time to time been devised to 
assist in the use of chloroform, many are deserving of no better 
name than life-traps; and in this connection one naturally finds 
himself wondering at the character of contrivances which, particu- 
larly in the earlier history of chloroform, were employed, even by 
the ablest men, in experiments directed to the testing of the general 
safety and results of the agent. I can never read of the white mice, 



446 ORAL DISEASES AND SURGERY. 

and guinea-pigs, and cats, and bell-jars of these pioneers, without 
wondering that it should never have occurred to the experimenters 
that animals might as readily die from lack of proper respirable air 
as from the effects of chloroform. 

In using pure chloroform, it is most desirable that there should 
be the fullest admixture with air; with this intention we use the 
sponge, first softening it with warm water, which water is to be 
well squeezed away. The respiration should be easy and natural, 
and the patient fully en rapport with the operator. He should be 
given to understand that anaesthesia is but a gentle and harmless 
sleep, and that one should enter upon such a condition as he enters 
upon natural slumber. If such confidence can be secured, there will 
not be found much trouble in producing narcotism. Another plan 
of using the agent, and one which has many advocates, is to let fall 
drop after drop upon a napkin, laid loosely over the air-passages. 

However employed, the principal indication is to have the agent in 
proper dilution and combination with atmospheric air: this secured, 
any mode of inhalation must be a proper one. Insensibility, as re- 
marked by Dr. Snow, is not caused so much by giving a dose as by 
performing a process. Nature, continues this gentleman, supplies 
but one mixture of diluted oxygen, from which each creature draws 
as much as it requires; and so, in causing narcotism by inhalation, 
if a proper mixture of vapor and air is supplied, each patient will 
gradually inhale the requisite quantity of the former to cause in- 
sensibility, according to his size and strength. It is desirable to 
vary the proportions of vapor and air, but rather according to the 
purpose one has in view, whether medicinal, obstetric, or surgical, 
than on account of the age or strength of the patient; for the respira- 
tory process bears such a relation to the latter circumstances as to 
cause each person to draw his own proper dose from a similar at- 
mosphere in a suitable time. 

The induction of insensibility varies with the individual, or 
rather, I may say, with classes of individuals. One class will breathe 
quietly and slowly, until unconsciousness supervenes as if by a 
natural sleep : persons of this class are of the lymphatic temperament. 
The nervo-sanguine or bilious class are apt to become restive and 
frightened, and require a great amount of care and attention, being 
the most difficult to impress. The true and full nervous class, while 
timid and frightened, are apt to be impressed by a very few inhala- 
tions. There is one question that here arises in regard to the exhi- 
bition of timidity. When a patient becomes restive and excited, 



GENERAL ANAESTHESIA. 447 

shall the chloroformization go on? Yes, I would answer, if such 
exhibition is associated with mental disturbance produced by the 
chloroform ; for here it is not as the condition previously named, but 
is rather an hallucination. These patients should be forced rapidly 
beyond such states of excitement ; and here is the point in which the 
production of anaesthesia demands the greatest skill, courage, and 
judgment. I have over and over seen incompetent operators worry 
a poor creature into a most wretched condition simply by fearing to 
pass this Rubicon of excitement. If assured that all is right (and 
such assurance is to be derived from the general aspect of the 
patient rather than from any special signs), we are to get over this 
intermediate excitable stage as quickly as possible, and get over it by 
concentrating the chloroform. Patients laboring under this excita- 
bility will, often enough, assure you that they feel that another inha- 
lation will kill them ; that it is impossible to breathe; that the heart 
is laboring under a wonderful depression; with many complaints of 
like character. Such speeches are mostly to be taken cum grano 
salis : the practitioner must judge for himself. 

Before an operation of any magnitude is commenced, it behooves 
the surgeon to assure himself that his patient is in the proper anaes- 
thetic condition. Entire paralysis of the muscles of animal life is 
commonly received as indicative of such a state, — this being mani- 
fested in the lifeless falling of an arm when raised. But this is not 
strictly reliable, as to obtund sensation we are aware the posterior 
root of the spinal cord is to be affected, while loss of motion implies 
only anaesthesia of the anterior root. So quickly, however, does the 
action of the agent pass from the one to the other, that this sign 
is found to be one most convenient of acceptance. Dr. Snow, so 
far as I am aware, was the first to call attention to indications 
afforded by the eyelashes: this test I have depended on for years, and 
usually find it reliable. Just after unconsciousness is induced, remarks 
this observer, the eyelashes are often closed very strongly when their 
margins are touched, especially in females, and there seems to be a 
positive hyperaesthesia ; this, however, is only apparent, and arises 
from the control of the will being removed while sensibility remains. 
By continuing the chloroform the sensibility of the edges of the eye- 
lids diminishes, until, at last, they may be touched without causing 
winking. Under these circumstances, the most severe operation may, 
in almost every case, be commenced without pain. Upon this indica- 
tion of the eyelids, Dr. Snow thinks we may so entirely depend, as 
ordinary cases are concerned, as to accept from them information as 



448 ORAL DISEASES AND SURGERY. 

to the exact extent of anaesthesia existing. When, for instance, he 
says, touching the margins of the lids causes very slight and lan- 
guid winking, the patient will commonly flinch a little if the knife is 
used, but only in a manner that can be easily restrained and that 
will not interfere with the majority of operations. 

Three degrees of narcotism are described. " The first degree in- 
cludes all the effects of chloroform that exist while a patient retains 
a perfect consciousness of where he is and what is occurring. In 
the second degree there is no longer correct consciousness. The 
mental functions are impaired, but not necessarily suspended. In 
the third degree there are no longer any voluntary motions." 

The circumstances which influence or modify the effects of chloro- 
form are thus considered by Dr. Snow, than whom, perhaps, there 
is no one whose observations have been of a more extended or 
thorough nature; although it is not to be overlooked that he was so 
enthusiastic in this direction that perhaps, in some instances at least, 
his prejudices may have influenced somewhat his judgment. 

" I arrived at the conclusion," says he r " after much careful obser- 
vation, that chloroform might be given with safety and advantage 
in every case in which the patient requires, and is in a condition to 
undergo, a surgical operation. And having acted on this conclusion 
for several years, I have found no reason to change it. It is de- 
sirable, however, to pay attention to every circumstance connected 
with the health and constitution of the patient before exhibiting 
chloroform, as many of these circumstances influence its effects." 

Age. — " The age of a patient has considerable influence in modi- 
fying the effects of chloroform. It acts very favorably on children. 
They sometimes oppose the inhalation of it as long as they are con- 
scious, but it does not occasion the rigidity and struggling, after loss 
of unconsciousness, which are sometimes met with in the adult. 
Anaesthesia is generally induced with a less amount of narcotism of 
the nervous centres in children than in grown persons. 

" The effects of chloroform are more quickly produced, and also 
subside more quickly, in children than in adults, owing, no doubt, to 
the quicker breathing and circulation. It often happens, however, 
that when the insensibility has been kept up for some time, say 
twenty minutes or half an hour, in a child, it is followed by a natu- 
ral sleep of a few hours' duration, provided there is no painful 
wound or other cause to prevent the sleep. I have given chloroform, 
in a few cases, as early as the age of eight or ten days, and in a con- 



GENERAL ANESTHESIA. 449 

siderable number of cases before the age of two months. And I 
own memoranda of hundreds of cases under a year old to whom I 
have administered this agent. There has been no ill effect from it 
either in these cases or in those of children more advanced in life ; 
and it is worthy of remark that none of the accidents from chloro- 
form which have been recorded have occurred to young children." 

There is nothing peculiar in the effect of chloroform upon people 
advanced in years, except that its influence subsides rather slowly, 
on account of the slower breathing and circulation. I have given 
chloroform to many patients over seventy-five years of age, and to 
one as old as ninety years. 

Strength or Debility. — " The comparative strength or debility 
of the patient has considerable influence on the way in which chloro- 
form acts. Usually the more feeble the patient is, whether from ill- 
ness or any other cause, the more quietly does he become insensible ; 
while if he is strong and robust, there is very likely to be mental 
excitement in the second degree, and rigidity of the muscles, and 
probably struggling, in the third degree of narcotism. Patients in 
a state of debility resemble children, not only in coming quietly and 
easily under the influence of chloroform, but also in the circumstance 
that the common sensibility is suspended with less narcotism of the 
nervous centres than is generally required in robust persons. Chil- 
dren, and persons in a state of debility, have usually an acute sen- 
sibility, which causes them to suffer pain from very slight injuries, 
but this sensibility is more easily suspended by chloroform than the 
less acute sensibility of robust persons." 

Hysteria. — " Patients who are subject to hysteria sometimes 
have symptoms of the complaint, such as sobbing, crying, or laugh- 
ing, as soon as consciousness is suspended, or even impaired, by the 
chloroform ; but these symptoms can always be subdued by pro- 
ceeding with the inhalation.* 

* Chloroform in hysteria is, I think, one of the most valuable medicines of 
the Materia Medica, while, on the contrary, sulphuric ether is, so far as my 
experience goes, most decidedly objectionable to such patients. I have treated 
females afflicted in this way where ether had been used by the pound with no 
other effect seemingly than increasing, intensifying, and prolonging the par- 
oxysm ; yet with a very few inhalations of chloroform I have had the pleas- 
ure of seeing these persons fall into the most natural slumber, and after rest- 
ing quietly for hours, the slumber prolonged, perhaps, as sometimes has seemed 
indicated, by occasional repetition of the inhalation, I have seen them, again 
and again, awake perfectly recovered. 

29 



450 ORAL DISEASES AND SURGERY. 

"In some persons who are subject to hysteria the breathing be- 
comes excessively deep and rapid while inhaling chloroform.* This 
usually occurs just as the patient is becoming unconscious, but in a 
few cases even earlier, and the patient is aware of the impulse to 
breathe in this manner. After this kind of hysterical breathing has 
lasted a minute, the patient generally rests nearly a minute without 
breathing at all, after which the respiration becomes generally very 
natural. Chloroform is to be given very sparingly during the vio- 
lent breathing, or else withdrawn altogether for a minute or two." 

Pregnancy. — It is not generally thought that there is anything 
in this condition objectionable to the use of chloroform. 

The Menstrual Period. — This period is certainly not to be pre- 
ferred or selected as an occasion of chloroform exhibition. Yet 
there is nothing at all in the condition adverse to such exhibition. 
The controlling effect of the agent over hysterical symptoms has just 
been remarked, and such irritability of the system is the only pecu- 
liarity of this state. Indeed, it is very common that the hysterically 
inclined female is compelled to resort to chloroform, particularly in 
conditions of dysmenorrhea. 

Diseases of the Lungs. — "Affections of the lungs sometimes 
cause a little difficulty and delay in the administration of chloroform, 
as the vapor is liable to excite coughing when the mucous membrane 
of the air-passages is irritable. The inconvenience is, however, con- 
fined to the time of inhalation, for the cough is generally relieved 
after ward.f 

" I have given," says Dr. Snow, " chloroform for surgical purposes 
in many cases where phthisis was present, and in several patients 
who had suffered from haemoptysis, and have not seen any ill effects 
from its use in these cases. Chloroform has, indeed, often been 
inhaled with advantage to relieve the cough in consumption. The 

* Dr. Snow, in his paragraph, remarks the supervening of this condition 
after the first few inhalations, but, according to my own experience, it is as 
uncommon when chloroform is used as it is common in the employment of 
ether. When, in administering ether, I see the slightest signs of hysteria, 
either in male or female, I always expect at once to control them by replacing 
the ether with chloroform. 

-j- This difficult}*, as observed not only by Dr. Snow, but also by nearly 
all writers on anaesthesia, I have found to be almost, if indeed not entirely, 
obviated by preceding the exhibition with a tablespoonful of thick mucilage 
of gum acacia, the patient allowing it gradually to lose itself over the mucous 
surfaces. 



GENERAL ANAESTHESIA. 451 

cases of chronic bronchitis in which chloroform is administered and 
for surgical operations are still more numerous." 

Disease of the Heart. — " There is a very general impression 
that the use of chloroform is unsafe when disease of the heart 
exists, more particularly fatty degeneration of that organ. This 
belief has been encouraged by the circumstance that this affection 
has been present in a few of both the real and alleged deaths from 
chloroform, and also by the fact that, in the accidents that have been 
really due to chloroform, the heart has been the organ on which it 
has exerted its fatal influence. When we come to investigate these 
cases, however, we shall find reason to conclude that the heart has 
probably been diseased in quite as great a proportion of the patients 
who have taken chloroform without ill effects as of those who have 
succumbed under its influence. As regards my own practice," says 
Dr. Snow, " the only case in which death could in any degree be 
attributed to the chloroform, was one in which there was extreme 
fatty degeneration of the heart; but, on the other hand, I have 
given chloroform in numerous cases without ill effect where the 
symptoms of this, as well as of other affections of the heart, were 
present in a marked degree. Indeed, I have never declined to give 
chloroform to a patient requiring a surgical operation, whatever 
might be his condition, as I early arrived at the conclusion that this 
agent, when carefully administered, causes less disturbance of the 
heart and circulation than does severe pain. Wherever," continues 
Dr. Snow, " I have had an opportunity of seeing an operation per- 
formed without chloroform, I have carefully examined the pulse, 
and although none of these operations have been of a very severe 
nature, I have found the circulation to be much more disturbed than 
it would have been by chloroform carefully administered. The pulse, 
in most of these cases, has been exceedingly frequent during the 
operation, and in some instances it has intermitted to an unusual 
extent. 

" In one instance I had an opportunity of witnessing a similar 
operation on the same patient, first without chloroform, and after- 
ward under the influence of the agent. In the operation, which was 
lithotrity, at the first operation I began to feel the pulse just when 
the patient saw the lithotrite about to be introduced. It was 120 in 
the minute. As soon as the instrument was introduced the pulse 
increased to 144, and immediately afterward it became uneven, irreg- 
ular, and intermitting. I could not count more than three or four 
beats at a time ; and occasionally, when the pain seemed greatest, 



452 ORAL DISEASES AND SURGERY. 

and the man was straining and holding his breath, the pulse was 
altogether absent for four or five seconds. In order to ascertain 
whether the absence of the pulse at the wrist might not depend on 
the pressure of the muscles of the arms, caused by grasping the 
table, I applied my ear to the chest, and found that there was no 
sound whatever to be heard during the intervals when the pulse was 
imperceptible. It was evident that the patient held his breath till 
the right cavities. of the heart became so distended as to stop 
the action of the organ till the respiration returned. The man did 
not complain or cry out during the operation. 

"A week afterward the lithotrity was repeated, but on this occa- 
sion I administered chloroform. The pulse was 120 in the minute 
when the patient began to inhale the chloroform, but it became 
slower as he was made unconscious, and it was regular during the 
operation. It was only toward the end of the operation, when the 
effect of the agent was allowed to diminish, and when the man 
began to strain a little, though not yet conscious, that the pulse in- 
termitted slightly, passing over a single beat occasionally. There 
were none of the long intermissions of the pulse observed on the 
former occasion. 

"It is very evident that if the above-mentioned patient had been 
the subject of any affection of the heart which weakened or embar- 
rassed its action, he would have run a much greater risk from the 
pain of the first operation than from the inhalation of the chloroform 
in the second one. 

"In a few of the patients having the arcus senilis of the cornea, 
a weak, intermitting, or irregular pulse, and other signs of fatty 
degeneration of the heart, there have been a feeling of faintness and 
a tendency to syncope as the effects of the chloroform were sub- 
siding, especially when the operation had been performed in the sit- 
ting position ; but these symptoms have soon subsided, in all cases 
I have met with, on placing the patient horizontally, with, or with- 
out, the help of a little ammonia to the nostrils." 

Cerebral Diseases. — "Affections of the head offer no obstacle 
to the administration of chloroform. I have given it to several 
patients who had suffered previously from an attack of apoplexy; 
some of them still retained the paralysis resulting from the attack, 
but the chloroform has not been attended or followed by ill effects 
in any of these cases." 

The following interesting and most instructive case is mentioned 
in this direction : 



GENERAL ANESTHESIA. 453 

" The 31st of October was a day appointed by Mr Fergusson to 
perform lithotrity on a gentleman seventy-eight years of age, who 
had a phosphatic calculus in his bladder. He was a patient of Mr. 
Propert, and Mr. Fergusson had removed a similar calculus by litho- 
trity, and I had given him chloroform at each of the operations, and 
it was arranged that he should have chloroform on the present occa- 
sion. Mr. Propert informed Mr. Fergusson and myself on our arrival 
that his patient had, the night before, an attack resembling apoplexy ; 
he had been insensible ; the breathing had been stertorous, the pupils 
dilated, and the face very red and congested. Mr. Propert had 
caused him to be cupped to fourteen ounces, and had given him 
twenty grains of calomel in the course of the night, and in the 
morning he was as usual, and remained so at the time of our visit. 
We considered the case with Mr. Propert, and, as there were reasons 
for not postponing the operation, it was determined that he should 
inhale the chloroform rather than be subjected to the pain. The 
vapor acted very favorably : he recovered his consciousness a few 
minutes after the operation, and expressed himself as feeling quite 
well." 

Insanity. — Chloroform acts on insane patients just as it does on 
others : when the effects subside they are in the same state of mind 
as before. Mr. Snow remarks the suspiciousness of the insane, but 
gives his experience where teeth have been extracted and other 
operations performed which it would have been impossible to ac- 
complish in the same individual without resorting to inhalation. 
The employment of chloroform in the delirium of mania a potu has, 
through the experiments of Dr. Ely McClellan, of the United States 
Army, lately been revived, and commanded much attention, the 
successes of this gentleman having been sufficiently verified by 
practitioners in every part of the country: given in drachm doses, 
pro re nala, it seems completely to break the paroxysm, causing 
the patient to fall into profound sleep, from which, after eight or 
ten hours, he commonly awakes entirely relieved. In delirium, 
however, the chloroform is to be taken into the stomach, and not 
breathed. 

I may close this consideration of chloroform by again remarking, 
as alluded to in the commencement of the chapter, that the agent, 
if one feels justified in using it, is far to be preferred in oral surgery 
to the ether; a profound impression created through chloroform will 
not unfrequently continue through quite a prolonged operation ; or, 
if it be necessary to renew the inhalation, the desired impression 



454 ORAL DISEASES AND SURGERY. 

is generally made with great rapidity. Operations about the mouth, 
unlike most other surgical services, require to be executed with 
great rapidity ; therefore is it a necessity to be as little interfered 
with as possible: an impression, apparently very profound, made 
with ether, is apt to be broken in the very first shock of an oral 
operation. This first step may be of a character starting, in some 
instances, frightful hemorrhage, and which can be combated only 
at the completion of the operation; to have a patient pass from con- 
trol at such a moment, and under such circumstances, is sometimes 
a matter of serious concern. If one has not used chloroform up to 
this time, and the article is at all convenient, it is very apt to be 
given to the patient in a quite free manner. I certainly do desire 
heartily to recommend it, but prefer, as my own practice is con- 
cerned, to combine it in varying proportions with sulphuric ether. 
I have in this chapter used in many instances the strong authori- 
tative experiences of Dr. Snow. I am convinced of the truth of all 
that he maintains ; his experience with the agent has certainly been 
of the most extensive nature: personally, however, I am still afraid 
to use chloroform except in conjunction with ether ; and while such 
fear may not be well grounded, yet, as it exists, I cannot do other- 
wise than give expression to it. At this day it were certainly idle 
to attempt to deny that many deaths have resulted from the use of 
chloroform ; and a large proportion of these accidents have occurred 
in the hands of eminent and skillful men, and where every possible 
scientific precaution had been taken. 

Again, the accidents have seldom or never been traceable to an 
overdose of the agent ; the deaths have never occurred from narco- 
tism, but from direct, immediate, and unforeseeable paralysis of the 
heart. I have not overlooked the fact that fatal results happening 
while chloroform was being used might not be owing to this agent. 
Certainly there are cases enough on record justifying such a conclu- 
sion, — cases with which every surgeon must be familiar; but, on 
the other hand, there are instances of such doubt, or perhaps I 
should rather say, of such certainty, that one may incline to err on 
the side of discretion. 



NITROUS OXIDE GAS. 

Except as its use in such speedily-performed operations as the 
extraction of teeth is concerned, it would not seem that nitrous 
oxide will ever be found applicable to oral operations (at least, as 



GENERAL ANAESTHESIA. 455 

at present we know how to get the effects of the agent). In this 
opinion, I am aware, others may not feel disposed to agree with me, 
and it may very well be that I am wrong, as I have had little ex- 
perience with the agent. Be this as it may, however, ether and 
chloroform appear so satisfactory, and every way reliable, and at 
the same time are so convenient of, use as compared with the gas, 
that I imagine they will continue to hold the supremacy. 

Should it be felt by any experienced in such matters that the pro- 
toxide of nitrogen as an anaesthetic possesses advantages over ether 
and the chloric-ether, they will hail with satisfaction the lately per- 
fected attempt to furnish the substance in liquid form. A convenience 
called the " Surgeon's Case" is now to be procured, in which in a 
cylinder one foot long by three inches in diameter are stored by 
compression one hundred gallons of the gas. This cylinder is 
refilled at the depot as may be required. The other contents of the 
case are the constituents of the required inhaling apparatus, — the 
rubber bag, tubing, and mouth-piece. The whole weight of the case 
and contents is fifteen pounds.* It is a neat arrangement, and 
highly recommends itself. 



*The subject of nitrous oxide will be found considered with a fullness 
which may be said to be exhaustive, in several elaborate essays, written 
respectively by Drs. George J. Ziegler, Geo. T. Barker, and F. R. Thomas, 
of Philadelphia. 



CHAPTER XX. 



ARTIFICIAL DENTURES. 



PIYOT TEETH. 



Passing to the consideration of a mouth in which certain teeth, 
or it may be the whole denture, have been lost, the surgeon, having 
the assistance of a mechanical dentist, finds it in his province to 
consider the replacement of the lost organs. 

Lost natural teeth are replaced, either through the pivoting of 
crowns upon healthy roots which may remain, or by adjusting the 
substitutes to plates of various kinds. 

Pivot Teeth. — The pivoting of a crown to a root (Fig. 186) is an 
operation which has its commendation or condemnation 
r ig. 186. | Q ^g f ea t U res of each particular case. It is to be ac- 
cepted as a cardinal principle that only the perfectly 
vital healthy root is able to support an artificial crown. 
Pivot teeth are found most useful and satisfactory 
when confined to the six anterior roots, superior or 
inferior, — the incisors, central and lateral, and the cus- 
pidati ; although, except where bifurcation or great flat- 
ness may exist very near the neck, they are frequently 
attached to the roots of the bicuspidati. The incisor 
r To\oot° G ro °ts, however, are those to which these crowns are pre- 
eminently adapted, and to which it may prove as well 
to confine them as closely as circumstances shall permit. 

Pivot teeth are always to be considered as promising most useful- 
ness and stability when possessed of lateral support by the presence 
of contiguous natural teeth : hence it is that while one or two of 
such teeth having an alternate relation with intervening natural 
organs will be found — cseteris paribus — to answer excellent ends, 
where three or four are required contiguously, experience demon- 
strates that it is better to employ a plate. 

Satisfied of the desirability of using a pivot tooth, and of the 
(456) 



ARTIFICIAL DENTURES. 457 

ability of a root to support a crown,* the first steps in an operation 
consist in such cutting and filing manipulation as pertains to a 
jointure between the two parts, and in a reaming out of the pulp 
canal for the reception of the pivot. 

A case presenting itself as a pivoting operation will commonly be 
found in the condition of a half-destroyed crown with a pulp dead, 
or, it may be, only semi-devitalized. The latter condition of the pulp 
existing, a first step will reside in its destruction. To accomplish this, 
as little disturbance as possible is to be provoked. If such pulp be 
exposed, the very best plan to pursue is to prick into it, with any 
convenient needle-pointed instrument, arsenic and atropia, equal parts 
of which have been rubbed up in creasote. From a tooth in my own 
mouth I have had such a semi-devitalized pulp removed in the space 
of fifteen minutes. It is done without pain, and is a simple opera- 
tion which may be repeated by any person who possesses sufficient 
delicacy of touch. A pulp so treated limits irritation to the closest 
confines. When the pricking instrument is felt to strike against the 
foramen of the root and sensibility is lost, it is only necessary to 
introduce a barbed broach, and, by a few turns in the canal, the 
mangled pulp is caught and withdrawn. 

In a broken tooth where a cavity of decay does not expose the 
pulp, such exposure may be made by delicate manipulation with the 
drill or excavator, or otherwise it is to be treated by the introduc- 
tion of the arsenical preparation into the existing cavity, and the 
sealing up of the same for a period varying from twelve to twenty- 
four hours, according to the density of the tooth. A piece the size 
of an ordinary pin-head will be found sufficient to destroy a pulp. 
The pulp thus destroyed, the crown of the tooth may be cut off, as 
now to be described. A previous mention, however, is to be made 
of those accidents, not uncommon, which have caused the fracture 
of a perfectly healthy tooth. If in such cases, as is most likely, 
the shock has excited pulpitis, and, it may be, periodontitis, a first 
attention is to be directed to the resolution of such conditions. No 
immediate attempt is to be made to destroy the pulp, unless indeed 
it be exposed, when it is to be pricked as before described ; but a 
local vigorous antiphlogistic treatment is to be instituted and con- 
tinued until the practitioner is satisfied that resolution is not to 
be effected. Quiet secured, the broken tooth is allowed to remain 
strictly at rest until all irritability has subsided, when a spear drill 

* It is not to be understood that an attempt is not to be made to restore 
an unhealthy root to the healthy state. 



458 ORAL DISEASES AND SURGERY. 

is to be used for the production of a receiving cavity into which the 
arsenious paste is to be applied as before directed. Another way 
to employ the paste with such broken teeth is to build about the 
edges of the fracture a ring of gutta-percha, to be accomplished by 
trailing a solution which has been made by covering parings of 
gutta-percha with chloroform ; the chloroform, quickly evaporating, 
leaves the gutta-percha firmly adherent to the parts upon which it 
has been laid. Within the ring thus secured, the paste is to be laid 
and covered in with the same solution. Teeth from the accident of 
fracture are sometimes made so sensitive as to render it impossible 
to use the drill. The means just suggested will meet the indication. 

If the gutta-percha should be found not to adhere with sufficient 
tenacity by this method, it will be necessary to excavate a groove 
in the face of the denture, and, after thoroughly drying the parts, 
build on piece by piece the ring of "Hill Stopping," or red gutta- 
percha, when the paste may be placed in position and covered with 
a portion of the same material. 

Sometimes it is found also to happen that nodules of secondary 
dentine exist in the pulp, interfering with the absorption of the 
arsenic ; in such cases it will be necessary to repeat the application 
a number of times, or else expose the organ and prick it. Resistance 
to arsenical applications is quite diagnostic of the presence of pulp 
nodules. (See chapter on Odontalgia.) 

To cut the crown from a root, the first instrument required is the 
excising forceps. This is used in anticipation of the file, the crown 

Fig. 187. — Upper Excising .Forceps. 




being cut away little by little until the neck is uncovered. This 
extent of excision being accomplished, it is prudent to give the part 
a rest of a day or two ; it is a safe plan, although certainly not in 
all cases, or indeed even in the majority, a necessity. 

In place of the forceps some operators prefer the saw for excising 
a crown ; it will not, as a rule, be found so convenient of employ- 
ment, and is more apt to provoke inflammatory response. It is not 
amiss, however, to have such an instrument, as occasionally it will 
be found quite useful. 



ARTIFICIAL DENTURES. 

Fig. 188. — Saw for Excising Crown. 



459 



Fig. 189.— 
Piyot Files. 



Following the excising forceps is the pivot file. This instrument, 
being half round, cuts a concave face on the neck of the root, 
which aspect of face is seen to correspond with the 
accommodation required by the neck face of the 
artificial crown, which, as it comes from the labor- 
atory, and is used, is convex. 

In filing down the natural root, the most judicious 
gentleness is to be combined with the necessary 
dispatch. The file used at first should be sharp, so 
as to accomplish the required amount of work with 
the least irritation, and should be used until the 
gum is fairly touched ; the sharp file is then to 
be exchanged for a comparatively dull one, with 
which the now concave face of the root should be 
smoothed until a marked bleeding from the gum 
occurs all around the root. The object of this is to 
insure an accurate covering of the joint between 
root and pivot tooth by the healed gum. It is 
sometimes, though very rarely, the case that with 
previously irritated roots this preparatory opera- 
tion should be divided into several sittings, mean- 
while pursuing antiphlogistic treatment ; but the 
cutting with the dull file which is to take off the 
root below the gum is to be the step immediately 
preceding the attachment of the new crown, other- 
wise the gum will be found to fall over the root 
and thus partially cover its surface. 

During the process of cutting down the natural 
crown, or, to make a rule, we may say at that stage 
which is to employ the dull file, the preparation of 
the canal is to claim attention. To effect the re- 
quirements here demanded, rose or bur drills of 
various sizes may be employed, commencing with 
one received into the natural canal, and increasing 
seriatim until a sufficient diameter is secured, — 
such diameter being in correspondence with the size 
of the pivot used. The depth to which a canal may 
be reamed, and also the diameter, depend upon 






460 ORAL DISEASES AND SURGERY. 

the size and density of the root ; a rule applicable to all cases can- 
not be given : it is to be deemed necessary, however, that sufficient 
circumference and depth be secured to insure the retention of the 
pivot; half the length of a root may commonly be reamed with 
impunity. 

The process of reaming completed, a delicate spear drill is to be 
passed into the continuation of the canal, and the parts cleansed to 
the apex. This secondary canal is then to be filled with gold (see 
Filling Pulp Canal) ; this accomplished, the root is ready for the 
crown. 

The selection of a crown for the root considers — first, the shade or 
color, which is to correspond with that of the neighboring teeth ; 
second, the shape and adaptability of the crown. By having in 
one's possession a few hundred artificial crowns, it is quite pos- 
sible to find among them many of such perfect match as to render 
the slightest alteration unnecessary. Third, it is requisite to have 
the pivot canal in the crown and that in the root so correspond that 
when the jointure is made the crown occupies its right position. 
To be satisfied of such proper relation of parts, the crown and root 
may be put together for the moment with a pivot of round match- 
stick. It is suggested, and practiced by some, that when there is 
lack of natural correspondence in the canal of the root, the required 
direction shall be given by the drill: this, however, is to be con- 
demned as bad practice ; it is much better to seek a new crown. 

To have an accurate adaptation of the crown to the root is most 
desirable : this may require some grinding of the crown ; and to know 
just where to grind makes it necessary that the touching points be 
recognized. Such information maybe secured by coating the surface 
with a film of wax ; putting the parts now together, the wax over- 
j^Q 190 lying the points implicated will, of 
course, be found indented and dis- 
placed. A plan even better than that 
just described is, immediately upon 
having the root prepared, to take an 
impression of it and the contiguous 
| (o^^jp teeth in wax (see Taking Impres- 
§k vsjb ^^^pj g^=^ ^^ sions), and, having made a model of 

plaster of Paris, fit the crown to the 

Hand-Lathe. model.' 

To grind a tooth, a stick of corundum is used by many. Such 
sticks are to be procured at the furnishing depots for a few cents. 




ARTIFICIAL DENTURES. 



461 



Fig. 191. 



A better means is found, however, in the employment of a lathe ; 
of these instruments the greatest variety is offered. The smallest 
hand-lathe, however, is commonly found sufficient to meet all the 
requirements. Fig. 190 represents such a lathe: it may be attached 
temporarily to any stand conveniently at hand. This lathe is entirely 
noiseless. Having neither cog-wheels nor belt, it is free from oil, 
dirt, and the trouble of adjustment. The motive power is commu- 
nicated hj friction gained by covering the small wheel, or pulley, 
with a rubber ring which comes in contact with the inner surface 
of the driving-wheel. The driving-wheel is six and a half inches in 
diameter ; the small wheel, two inches in diameter ; and the weight 
of the lathe is two and three-quarter pounds. 

A form of lathe which, being worked by 
the foot, leaves both hands at liberty, is repre- 
sented in Fig. 191. Such a lathe is in many 
respects preferable to the first: it is certainly 
more convenient to the operator. This lathe 
has a movable column and table, and is 
capable of being elevated eight inches : it is 
made to accommodate the operator in either a 
sitting or a standing posture. 

As the grinding instrument, wheels of corun- 
dum are used on these lathes ; the surgeon 
should provide himself with five or six of these 
wheels, of varying sizes. 

Crown and root prepared, the pivot is the 
next consideration. 

A pivot is made either of wood or metal. 
A wood pivot is only to be made of thor- Foot-Lathe, 

oughly-seasoned and firmly-compressed hick- 
ory: a box of such pivot sticks, which may be purchased at a depot at a 
cost of twenty-five cents, will set hundreds of teeth ; it is best thus to 
provide one's self. To use the wood pivot, the operator commences 
by securing the exact length required: this he learns with least 
trouble from his temporary pivot of match-stick. One end of this 
pivot is now fitted into the crown, the other being of a size corre- 
sponding with the canal in the root. Everything being thus pre- 
pared, it only remains to put the two together, and the operation is 
completed. 

It will occasionally, however, be found to happen that, in defiance 
of the nicest care which may have been exercised, there is slight 




462 ORAL DISEASES AND SURGERY. 

fault in the articulation of the cutting edge of the new crown with 
the correspondiug teeth of the lower jaw: this is commonly most 
easily remedied by filing away the impinging point on the natural 
tooth, or with the corundum stick it may be taken from the artificial 
crown. 

A second and much more serious complication is periodonteal in- 
flammation, the root becoming sore and painful. When such inflam- 
mation supervenes, it is to receive at once the required attention. 
(See Periodontitis.') 

Metal pivots are variously used. A common plan is to make a 
delicate tube of gold of such size as will permit its introduction into 
the drilled opening of the root (which in these cases should be made 
somewhat larger than is required for wooden pin pivoting, and 
should be bell-mouthed), leaving sufficient space around it to fill 
solidly with foil. A wire fitting this tube should be inserted into it 
to prevent its compression, and it should then be filled into posi- 
tion. The wire is then withdrawn, the tube filled either with wood 
or gutta-percha to prevent its injury, and the face of gold filed con- 
cave as though it were tooth structure ; this leaves only a ring of 
cementum exposed, thus effecting, from the exceeding durability of 
this substance, a very permanent and desirable result. An impres- 
sion is now taken in wax, a plaster cast is made, and from this, 
metal dies. A thin plate of gold is now struck between these dies, 
fitting accurately the face of the root, being filed to the exact shape 
of the face and outlines of circumference. Xext, the plate of gold — 
the cap having a hole drilled through its centre corresponding with 
the tube in the canal — being laid in place, a piece of gold pivot- 
wire is passed through it into its place in the tube, and secured 
with a small piece of adhesive wax. Cap and pin are now removed, 
invested in plaster of Paris, and the two soldered firmly together. 
The tooth here to be used is what is known as a plate tooth, — a 
tooth having pins of platina in its back. Selecting a tooth of this 
class to suit the case, the cap and pivot are slipped into place, and 
the crown, held in the exact position required, is fixed by a particle 
of wax. The whole piece thus joined together is now removed from 
the mouth : this is accomplished by inserting the blade of an exca- 
vator beneath the plate, and thus lifting it. The tooth is backed by 
a plate of gold having holes punched for the passage of the pins ; 
backing, tooth, and cap are now soldered together, and the fixture 
is completed, requiring only to be cleaned and introduced into the 
tube. If all is as desired, the gold pivot should then be tapped later- 



ARTIFICIAL DENTURES. 463 

ally very gently with a pivoting hammer, when it will be found, 
upon introduction, to remain with all necessary firmness. 

In a case such as just described it is not necessary that the 
surgeon do the mechanical work of swaging plates and soldering: 
— all this is indeed more in the province of the mechanical dentist, 
and to him it would seem proper and desirable to intrust it ; that 
he accomplish it satisfactorily it is only necessary to furnish him 
with the wax impression and the crown selected. Indeed, as we go 
on it will be seen that the accomplished mechanical dentist is as 
necessary to the oral surgeon as is the mechanician to a general 
practitioner. 

An improvement, as it is thought by some, on the plan just de- 
scribed, consists in the replacing of the root tube by a hollow screw, 
a screw-tap being used to cut the thread on its inner wall ; this 
screw, fixed in its place, is to be leveled with the face of the root 
and the operation completed as already described. 

In roots having canals not in correspondence with the position 
demanded for the new crown, the mode of using caps for the attach- 
ment of the new crown seems to afford all that can be desired, inas- 
much as when teeth are thus pivoted a correspondence between the 
canals of root and crown is of no importance, 

A condition indorsing most fully the employment of the tube is 
found in such roots as are somewhat decayed. Here, the tube being 
in place, after excavation of the part, as in any case of caries, it 
is solidly built in situ by a plug of adhesive gold. It is not the 
case, however, as is often affirmed, that this is the only mode of 
pivoting that may here be employed, since Dr. J. D. White, the 
eminent dentist, has fully and practically shown that to use the 
common wood pivot it is only necessary to ream a first canal of a 
size which takes in this decay and removes it, and from such first 
circumference to make a second of the ordinary character. Of 
course the pivot has a double diameter to correspond. 

A plan of pivoting which is to be considered a combination of 
the plans just described, consists in passing through the centre of a 
wood pivot, which has been drilled out for the purpose, a second 
pivot of gold wire ; such wire is found materially to strengthen 
the wood, and is thought by many to be the most desirable pivot 
that can be employed. 

Still another plan is the employment of what is known as the 
vulcanized pivot. This process is as follows. The root being pre- 
pared as previously described, by tubing, a wire of length sufficient 



464 ORAL DISEASES AND SURGERY. 

to protrude one-eighth of an inch or so beyond this tubing is flat- 
tened at one end and inserted into the tube; a tooth (usually a 
" vulcanite tooth") is adapted and placed in position ; the wire and 
tooth are next joined together with adhesive wax, and while yet 
warm are placed again accurately into position ; the wax pressed 
against the root face is cooled by jetting a stream of cold water upon 
it from a mouth-syringe, and the tooth, wax, and pin are carefully 
withdrawn. Moulds are then made of plaster as for vulcanite work, 
the wax is removed, vulcanizable rubber is introduced in its place, 
and the pin and tooth are secured firmly together by the vulcanizing 
process ; the rubber is then filed and polished. This is a very neat, 
easy, and altogether, as thought by many, desirable operation. 

A means of setting a pivot tooth founded on the ease with which 
the Mack screws may be worked, and applicable particularly to 
bicuspid and even molar teeth, consists in inserting into the pre- 
pared face three or more of the screws, and, having a tooth prepared 
for the purpose, of a box-like character, the chamber is filled with 
cement plombe, or any of the oxychloride preparations, and while the 
material is soft the tooth is put into place, being retained by the 
fingers until the cement hardens about the pins. A box tooth may 
easily be made by soldering a metal chamber to the pins of an ordi- 
nary plate tooth. 

Another plan, pertaining, however, only to the treatment of 
the root where this has been weakened by decay, consists in first 
making proper excavation of the diseased dentine and replacing it 
with oxychloride or amalgam. The material used having set, a 
pivot canal is reamed in its centre, and the operation completed by 
the use of the wood or wire-wooded pivot. Such mode of treating 
a decayed root is not, however, to be commended, as it takes but 
very little experience to demonstrate. A pivot inserted in osteo- 
dentine so exposed could have no permanency; while a periosteal 
degeneration — indeed, a necrosis of the root, quite as adverse — is 
almost certain to associate itself with the use of the amalgam. 

A method of setting a plate tooth on a root, and giving an addi- 
tional support by a rim of gold, which certainly has the merit of 
originality, is thus described by H. E. Dennet, of Massachusetts : 

''First cut the crown off; then tunnel out the root, by enlarging 
the pulp cavity, making it very large at the orifice, and smaller as it 
goes in, making retaining points at proper places. 

" Solder a platina point to a suitable plate tooth, the point being 
large where it is soldered, and a gradual taper bringing it nearly to 



ARTIFICIAL DENTURES. 465 

a point; then make it barbed or rough, so that it will not pull out 
after the tooth is set. 

"Having prepared the root and the tooth, put on the rubber dam ; 
fill the root to the point where the end of the pivot will meet it ; put 
on the tooth, and fill around the pivot (turning the tooth in and out, 
and laterally, as convenience requires, the pivot being easily bent 
without danger of breaking); build out to the natural form of the 
tooth, using first soft gold, then that which is partially adhesive, 
then adhesive." 

"The writer of the above," says Dr. J. H. McQuillen, "placed 
in my hands the root of a tooth, with a plate tooth attached in the 
manner described. The operation was very skillfully performed, and 
the plan proposed is certainly preferable to building out a golden 
crown, which, however perfectly executed, cannot be said to add a 
charm to the smile of beauty, although it may prove useful in mas- 
tication." 

The restoration of partly-fractured crowns is an operation which, 
as belonging to the front teeth, would seem to be worthy of more 
attention than it has heretofore received. As an example in such 
direction of what may be accomplished, the following case from the 
practice of Chas. J. Essig, D.D.S., is well worthy of being quoted: 

" The patient, a student of the Philadelphia Dental College, had 
the misfortune, ten years back, to break off, by a fall, about two- 
thirds of his right central incisor; in such condition he applied for 
relief from his deformity. 

11 The idea," says the gentleman whose practice is quoted, " of 
restoring its shape by what is known as ' contour-filling' was 
abandoned as soon as thought of, as was also that of the usual 
method of pivoting, for the following reasons : First, we would be 
obliged to cut away, and consequently lose, the substantial body of 
the tooth, with its enamel covering, and depend upon the frailer por- 
tion, the root. Secondly, the difficulty of matching in general ap- 
pearance the adjoining teeth, they being somewhat peculiar. And 
lastly, the knowledge that the period of usefulness of pivoted teeth 
is, under the most favorable circumstances, a short one. So, as 
neither of these methods afforded the two important desiderata of 
permanency and natural appearance, I decided to splice the broken 
tooth with a piece of porcelain. This was done, and the contour 
perfectly restored. 

" The method of proceeding was as follows. The vitality of the 
tooth had been destroyed by the accident, and some years after the 

30 



466 ORAL DISEASES AND SURGERY. 

pulp canal had been filled with gold. The fractured portion pre- 
sented an uneven edge and surface, which extended diagonally in- 
ward and upward toward the adjoining central. The first step was 
to remove the irregularities and obtain a perfect edge and a level 
surface, by means of a flat file. I then drilled up, following the pulp 
canal, to the depth of one-quarter of an inch, with a No. 16 drill of 
Palmer's set, following and slightly enlarging with a flat bur-drill. 
A small square gold box was next constructed, placed in the canal, 
and the four sides carefully and firmly filled around with gold. Into 
this box a pin made of platina gold fits accurately, the pin being 
split fully two-thirds of its length. At this point an impression was 
obtained of the broken tooth and the adjoining central and lateral 
ones. The pin, which had been left long enough to project three- 
sixteenths of an inch from the box, indicated in the impression the 
inclination of the canal. 

"A cross-pin plain plate tooth was next selected to exactly match 
in color the natural one ; it was ground away equally from the cut- 
ting edge and neck, so as to leave the pins as nearly as possible in 
the centre of the porcelain ; it was then fitted accurately to the 
tooth, and the cutting edge ground to imitate that of the adjoining 
central. 

"The piece was at this point found to nearly cover the mouth of the 
box, being almost as thick as the tooth itself. This difficulty was 
readily obviated by cutting off all that projected of the gold pivot 
and upon its end soldering a small plate, which fitted accurately 
upon the plane mentioned above as having been leveled with the 
file. A gold backing was then fastened upon the piece, and a slight 
concavity ground in the porcelain to receive the little plate. Before, 
however, finally soldering the piece to this plate, it was temporarily 
fastened with cement and tried in the mouth, as the plaster cast is 
liable to undergo some change in handling. It was then removed, 
after some little extra adjustment, invested in sand and plaster, 
and the backing and plate united by solder. 

" The piece can be removed and replaced with every facility, and 
the flat surface cleansed and polished whenever deemed necessary. 

"When in position, the line of union is almost imperceptible, and 
is really not observed unless attention is specially directed to it, and 
a very close examination made. 

" It has now been worn and thoroughly tested for several weeks, 
and its appearance is unchanged." 



ARTIFICIAL DENTURES. 467 



AKTIFICIAL DENTUKES— THE IMPKESSION. 

Plate Teeth. — The proper preparation of a mouth for the recep- 
tion of a plate implies that the operator consider in the relations of 
each case the hygienic, mechanical, and artistic considerations there- 
with necessarily associated: one mouth, the lips being long; the 
process full, the arch markedly concave, and of some depth ; the 
gums solid and resisting ; the submucous structure neither deficient 
nor excessive ; the teeth all absent, or such as may remain having 
harmonious relation ; temperament lymphatic ; such a mouth the 
merest tyro will accommodate. On the contrary, lips short ; process 
absorbed to a line; arch flat; gums irregularly flaccid and hard; 
teeth all gone, or, where some remain, inharmonious to a common 
articular relation ; temperament nervous ; such a mouth the most 
refined skill will scarcely serve to satisfy. 

A mouth before prepared to receive a denture, full or partial, is to 
be free from all roots which may have association with the parts to 
be occupied ; teeth irregular to the arch, and thus the source of de- 
ficient symmetry, or such as may interfere with a successful fitting of 
the artificial piece, or such as may be diseased and lacking in promise, 
these are to elicit attention and judgment. 

As a rule, a plate is not to rest upon. a root, healthy or unhealthy. 
The retention of an isolated tooth in the dental arch (all the others 
having been lost), however healthy and symmetrical, except it be in a 
position where a plate is not to go back of it, will be apt to antag- 
onize the merits of any denture, however perfect its construction. 
Soft teeth are not to be clasped. A cachectic mucous membrane is 
to be covered alone with a gold plate which has been alloyed with 
platinum, the baser materials being irritative. A turgid congested 
membrane is not capable of affording an impression which will allow 
a denture to be useful. Scorbutus, ptyalism, all unhealthy condi- 
tions are to be corrected before an impression is taken. Clasp teeth 
are to be freed from tartar, and (except when the denture is to be 
temporary) alveoli are to be absorbed. 

The Impression. — The first step in the construction of an artificial 
denture is the taking of an impression, or measurement. This is in 
the province of the surgeon, and consists simply in filling a tray (of 
which every size and variety are supplied at the depots) with soft- 
ened wax, plaster, or other impression material, and pressing it over 
the parts to be modeled. 



468 



ORAL DISEASES AND SUBGERY. 



Trays are of two general forms, the one being designed for the 
superior arch, the other for the inferior. 

Fig. 192. — Tray for Superior Jaw. Fig. 193. — Tray for Inferior Jaw. 




In selecting a tray for use in any special case, regard is to be 
had to the requirements of the case. First, such a tray is to be 
employed as shall admit of easy passage through the labial commis- 
sure. If an arch be deep in its palatine aspect, the tray used will 
demand to have marked convexity, or otherwise a common tray 
may be made to answer equally well for deep or shallow arches by 
having a false bottom. For application to the lower arch, a deep 
or narrow rim will be found demanded, as the process may be promi- 
nent or the reverse. In many mouths the site of the original alveo- 
lar process will be found to have entirely disappeared, leaving a 
perfectly flat surface, requiring a tray without the slightest flange. 

A tray is to be large enough to embrace the alveolar arch, leaving 
a space between the process and rim of about a quarter of an inch : 
it is to be deep enough to include the tubers of the upper jaw, or to 
touch the rami of the lower. If teeth long and prominent stand in 
either jaw, particularly the anterior of the lower, as is very com- 
mon, it may be found more convenient to use one so cut as to admit 
of such teeth passing through it. (Fig. 194.) This, however, is not 
a necessity, and not always even a convenience. 

Modifications on these common trays are numerous ; few practi- 
tioners, however, recognize sufficient merit in them to feel their con- 
sequence, finding rather in a skill the result of practice that which 
meets the various requirements. One of the very best impressions I 
have ever seen was taken with a piece of shingle, whittled for the 



ARTIFICIAL DENTURES. 469 

occasion, — but the hand that secured the cast was skillful and experi- 
enced. I have never in my own practice employed other than the 
character of trays here shown, and take it for granted that my trouble 
in getting satisfactory impressions has been about of a common experi- 

Fig. 194.— Tray foe, Passage of Teeth. 




ence with others. As suggested, however, I employ for the palatine 
arch the tray with a false bottom. Any one can make such false 
bottoms for himself by replacing, with pieces of tin or other metal 
bent into shape, the centre which is to be cut from the tray as 
shown in Fig. 192. Having a number of these bottoms (which 
should be somewhat larger than the piece removed), an operator 
finds himself requiring very few trays : half a dozen, or certainly 
a dozen, will be sufficient. 

The materials used for taking impressions are wax, plaster of 
Paris, and gutta-percha, either being used alone or in combinations. 
The inexperienced should begin with wax, as this is most simple 
and easy of manipulation, and at the same time quite capable of 
meeting all indications. 

Wax. — Two kinds of wax are used, the white and the yellow: of 
these, the white is, on some accounts, to be preferred. It will take 
a sharper impression, and has not its shape so readily deranged. 
An objection, however, is its want of plasticity as compared with 
the yellow, much more time and trouble being required to prepare 
it for the tray, while corresponding increase in pressure is demanded 
to force it into place, — the latter being a matter of importance where 
there is excess of the submucous cellular tissue. 



470 ORAL DISEASES AND SURGERY. 

Yellow wax, when pure, will, under all ordinary circumstances, 
afford a satisfactory impression. To soften it to a required consist- 
ency, which should be about that of dough, it is only necessary to 
work it at the fire, or over a spirit-lamp. Having selected a tray 
and observed the requirements of the special case, that is, the matter 
of depth of mouth, position of remaining teeth, and character of mu- 
cous membrane, whether hard or soft, yielding or unyielding, the wax 
is piled into the tray, being heaped in the middle if the mouth is 
deep, smoothed and flattened if shallow ; the wax to be very soft if the 
membrane be flaccid, of greater consistence if it be firm. The operator, 
if to take an impression of the upper jaw, stands behind, leaning over 
the head of the patient ; if of the lower, a position is assumed in front 
and to the right. The tray and wax being in the mouth, observa- 
tion is demanded to see if such correspondence of relation exists as 
will allow of the tray being carried into place. If care be not exer- 
cised in this direction, it will frequently be found that the cup is not 
far enough in the mouth, or perhaps is too far in, or too much to 
one or the other of the sides, so that, in carrying it into place, the 
sharp edge of some portion of the ridge comes down upon the gum, 
producing thus not only much pain, but rendering the impression 
good for nothing. A proper correspondence existing, it only remains 
to press the tray gently and steadily upon the arch, throwing the 
lip off should it interfere; a manipulation easily accomplished by 
running a finger between the lip and wax. A tray is never to be 
rocked into place, but rather carried with all steadiness until it is 
felt to be fixed and firm. Such a bearing obtained, the finger of the 
operator is to press the wax around the external face of the alveolar 
process, and where the false bottom has been used this is to be 
forced into the roof of the mouth. If the impression is of the lower 
jaw, then it is to be pushed with the finger against the internal face of 
the process as well as against the external. Before removing an 
impression of wax from the mouth, it should be allowed to remain 
a few minutes to harden. If, in the withdrawal, suction is recog- 
nized, the impression will almost certainly be found to prove a good 
one. A tray is held most steadily in the mouth by being supported 
on either side. 

Some operators, skillful in the use of wax as an impression mate- 
rial, find it necessary to employ a strand of silk or thread run 
through the wax just before introducing it into the mouth, that after 
securing the cast they may get it away by letting in air through the 
withdrawal of the string; the accuracy of the fit they obtain result- 



ARTIFICIAL DENTURES. 471 

ing in a suction which makes it otherwise difficult to get away the 
tray without a derangement of the impression. 

Before taking an impression, a mouth is to be cleared of saliva 
and mucus. This is most conveniently accomplished through rinsing 
with water and cologne, a teaspoonful of the latter to half a goblet 
of the former, or, if more convenient, the cologne may be replaced 
with alcohol. 

It is occasionally found recommended that immediately upon the 
withdrawal of a wax impression from the mouth it be plunged into 
ice-water, or otherwise that it be laid upon ice. This is a practice 
scarcely to be indorsed, the varying thickness of the wax resulting 
in unequal contraction. Unless hurry exists, it is much better to 
leave the cast to the existing state of the atmosphere. 

Sulphate of Lime — Plaster of Paris. — Plaster of Paris mixed 
with water into a paste is very widely employed as an agent in the 
taking of impressions. Plaster to be useful for such purpose must 
be of the very best quality; this implies that it has been well cal- 
cined and thoroughly pulverized. To employ it, the operator selects 
a tray, and filling it with the plaster, which has been semi-liquefied 
into a self-sustaining paste or batter, it is passed into the mouth in 
such manner that bubbles of air shall not be caught in the depth 
of the arch ; that is, the pressure which carries the mass into place 
is to be exerted gradually from the front backward. 

For plaster (employing it with the upper arch), cups or trays, as 
portrayed in Fig. 192, are commonly used. A plan, however, pre- 
ferred by many, consists in first taking an impression in wax, pre- 
cisely as has been directed. This secured, the surface of impression 
is indifferently cut away, simply with the view of securing what 
might be termed a fairly-fitting wax tray. Into this is now poured 
the plaster batter, and the whole is reintroduced into the mouth. 

Employing plaster for the lower arch, the tray as shown in Fig. 
193 is found entirely applicable. The requisites of a tray holding the 
plaster batter are, depth of flange sufficient to invest the alveolar 
face to an extent required to be covered by the paste, and that re- 
lation of arch which shall insure the plaster reaching every position 
of the part to be modeled. 

To take an impression in plaster, a patient is to be seated upon a 
low chair, and the head is to be inclined forward at an angle sufficient 
to prevent the falling of particles of the batter back into the fauces. 
The batter is to be of that consistency which neither allows it to run 



472 ORAL DISEASES AND SURGERY. 

from the tray, nor on the other hand so stiff and hard that it may 
not take the desired impression. The time required for setting is 
about three minutes; it may be shorter or it may be longer, — this 
depending on the character of the plaster used. The proper time 
for the removal from the mouth of a plaster impression is designated 
by the sharp, abrupt break to be seen by fracturing any inconsiderable 
and unimportant fragment, or by testing such portion as may be left 
in the mixing vessel. The matter of the time for removal is of very 
marked importance ; should the batter not have set, the cast is of 
course good for nothing. Should it, on the contrary, have become 
too solid, it might bring a portion of the mucous membrane with it, 
particularly in the case of the superior arch. 

Plaster that is slow in setting finds the defect removed by the 
addition of a small portion of common table salt, or, what is thought 
by some to be better, the sulphate of potash. 

Plaster of Paris as an agent for impressions finds its most conve- 
nient application to edentalous arches ; that it is used, however, 
with all success for partial sets of teeth is daily demonstrated. To 
take a partial impression it is found more convenient to have a tray 
with a false flange. After the batter has set, this flange is to be with- 
drawn, the bottom part of the tray being separated from the mass 
by means of the point of the knife-blade. Next, the impression is 
broken into pieces, each fragment being removed and preserved with 
all care. When all are away, each piece is coaptated with its 
fellow, thus restoring the cast. 

A second mode of taking a partial impression is found in the use 
of the wax cast : the plaster hardened, the heated blade of a knife 
separates the tray and wax ; the cup thus detached, the wax is 
quickly and easily removed from the plaster ; the exposed cast is 
now broken and treated as before described. 

Occasionally, indeed frequently, will it happen, that if the proper 
moment be secured, a plaster cast, even although it inclose several 
teeth, may be removed with reasonable facility without occasion for 
the fracturing as suggested. It is a point with many operators to 
try and save themselves this trouble, and with a reasonable experi- 
ence it is oftentimes to be avoided. 



Gutta-Percha. — This material, used alone, has never impressed 
the author as an agent of sufficient merit to warrant, in this direc 
tion, any special commendation. It is not only troublesome to 
manipulate, but from its tendency to undue contraction, as influ- 



■ 



ARTIFICIAL DENTURES. 473 

enced by circumstances, is tedious to look after ; it may not have 
comparison either with the wax or plaster. As an agent of admix- 
ture with wax, however, it is at times found a most satisfactory 
adjunct, insuring, as it does, an accuracy and sharpness in outline 
which is the highest recommendation of an impression. Gutta- 
percha alone, or in combination with wax, is used precisely the 
same as the pure wax, being softened by moist or dry heat, placed 
in the cup, and thus applied. When the gutta-percha alone is used, 
trouble may be experienced in getting it from the mouth, particu- 
larly in cases where teeth stand in an irregular relation to one 
another in the arch. 

The Model. — An impression of the mouth secured, the duty of 
the surgeon may be for the time ended in passing the tray to the 
mechanical dentist; or, if the interest of the matter invite him, he 
may pass to the succeeding step of making a model. I'his model 
is to be a fac-simile of the parts taken in the impression, and is 
made in a very few moments, as follows. If the impression be of 
wax, or gutta-percha, or of the mixture of wax and gutta-percha, 
the surface is to be thoroughly smeared with oil. Placing the tray 
now upon a table, a strip of paper, or lead, or waxed cloth, — any 
convenient thing, being of a length sufficient to encircle the circum- 
ference of the impression, and of a width not less than one and a 
half inches, — is to be placed around the tray, forming thus a tem- 
porary cup, the bottom of which is the impression. Taking now 
plaster of Paris sufficient in quantity to fill this cup, it is mixed with 
water into a batter of the consistency of cream, and in this state 
poured, with care, beginning at one corner, into the cup. When 
set solid, which will require two or three hours, the strip is to be 
lifted away, the tray removed by heating it slightly, and the wax, 
being warmed and softened, is picked away little by little by any 
convenient instrument, an ordinary pocket-knife answering the pur- 
pose quite as well as anything else. This model is the cast to which 
the mechanician works ; it is a perfect likeness of the mouth to which 
the teeth are to be fitted. 

In the case of the plaster impression the manipulations for se- 
curing the model differ somewhat from the above. The impression is 
to be thinly varnished, when dry is to be oiled, and the cream batter 
poured as before. When solid, the plaster impression is to be 
broken by the taps of a mallet, and thus in pieces lifted away. 

A succeeding step is the preparation of a plate to cover and fit 



474 ORAL DISEASES AND SURGERY. 

accurately the arch, — a plate of gold, platinum, or silver. We will 
not consider what is known as the vulcanite base, as it may not be 
accepted as a desirable material to be used in such relation. 

The preparation of the plate is the first relation of the surgeon 
with the mechanical dentist. The model being transferred, such 
plate may be quickly returned, ready to be tried in the mouth, the 
artist trimming and preparing the model to suit the requirements of 
his art. 

A matter, however, associating with the transfer of the model, is 
the character of plate required. Dental plates are of two kinds, — 
those supported by clasps or bands which are to pass about certain 
teeth, and those which depend on atmospheric pressure for support. 
Whether the one or other of these means may be employed depends 
entirely on the state of the mouth. When all the teeth are gone, 
there is, of course, but the single resource, the plate must be made 
to cover the full arch ; and, if the case is for the superior jaw. a 
cavity, occupying the centre of the palatine face, is to be made 
in the plate. Where certain teeth are present, these being of good 
shape to support bands, and of vigorous health and solid structure, 
it may be a matter of greater comfort to the patient to take advan- 
tage of such means to give him a plate which shall allow exposure 
to a greater surface of mucous membrane, — a matter of little conse- 
quence to the comfort of the lymphatic temperament, but of much 
concern to the nervous. 

The plate made, the next duty of the surgeon consists in securing 
what is called an articulation. This considers the bite, or the re 
lations of the artificial to the natural teeth. To secure an articula- 
tion which shall afford all requisite information to the mechanical 
dentist, it is necessary to proceed as follows : 

1. The Partial Denture. — TakiDg, as the most simple illustration, 
a plate upon which is to be placed a partial denture, say the six 
central teeth of the upper jaw. Try the plate in its place, and see 
if a fit has been secured ; fit is adaptability. Every part of a plate 
should rest evenly and solidly upon its base. If bands have been 
used, these are to inclose the special teeth to which they are related 
with the nicest accuracy, — they are to bug the teeth. Where 
atmospheric pressure is the means of support, the relation of parts 
must be so intimate that withdrawal of air from beneath the plate — 
effected through suction by the tongue — causes it to adhere to the 
parts with more or less tenacity. 

Satisfied of the adaptability of the plate, a succeeding step con- 



ARTIFICIAL DENTURES. 475 

sists in softening a piece of beeswax precisely as was done for the 
wax impression, and, moulding this on that part of the plate to be 
occupied by the new teeth, the patient is directed to close his mouth. 
This, as is seen, bites the lower teeth into the wax, thus affording 
knowledge of how the artificial teeth are to be set. Associated 
with this step is the trimming of the wax as to what shall seem the 
required length of the new teeth ; also the wax overlying that 
portion of the plate which covers the external face of the alveolar 
ridge may be so trimmed and moulded as to give proper support to 
the overlying lip. In such partial cases, however, it is not at all a 
necessity that anything more be done by the surgeon than secure 
the bite as directed. The mechanician, if at all an artist, has every 
required guide in the surrounding relations. The trimming and 
modeling he can do to suit himself. A shade, however, is required 
by him ; this is secured by matching in color the natural by an 
artificial tooth, of which latter the surgeon is to have at his com- 
mand quite a number. 

2. The Full Half-Denture. — A full half-denture implies the set 
complete either of the upper or the lower arch. We consider first the 
upper. Try the plate in the mouth to test its adaptability. If this 
is satisfactory, let the patient close upon it the teeth of the lower 
jaw. This affords information as to a general line at which these 
teeth will strike the plate. Take now the plate from the mouth, 
and build upon it a rim of wax of a height which, when in the 
mouth, will represent the required length of the new teeth. Such 
height is readily distinguished by trimming the wax little by little, 
until, in the various movements of the lips, as in talking, laughing, 
etc., it is seen to afford the promise of a natural expression. This 
secured, let the patient make a line of the impression of his lower 
teeth by slightly biting into the wax. Next the support of the lip 
is to have consideration. This pertains of course to the gum portion 
of the teeth. To afford here the requisite information to the artist, 
it is only necessary to model the wax until the external parts are 
seen to have their proper position. This is done by building upon 
the flange of the plate a rim of wax of such form and shape as are 
proved to be right by the impression produced on the contour of the 
lip. Accompanied by its shade tooth, the articulation is now ready 
to be again transferred. 

3. An articulation of the full lower denture is to be secured in a 
manner precisely similar to that practiced with the superior. 

4. The Articulation of a Complete Denture. — A complete denture 



476 ORAL DISEASES AND SURGERY. 

implies a set of teeth full above and below. Having the plates, the 
surgeon first places them, each in its proper place, and causes the 
patient to close the mouth that thereby some general conception of the 
relation of the parts may be obtained. Measuring now the length of 
the lips that an idea may be afforded of the required length of the new 
teeth, rims of wax are to be built upon the two plates precisely as 
before directed. This accomplished, each plate is to be placed in 
position, and the relations studied ; the lip is to be properly sup- 
ported, the wax is to represent the proper length of the new teeth, 
and the arches are to have such relation with each other that it 
is seen that the tongue is accommodated with the room required 
for its untrammeled movements: likewise is it to be observed that 
the line at which the rim of wax rests upon each plate is calculated 
to throw the centre of gravity of the new teeth on a bearing which 
antagonizes any tendency in the plate to tilt. This latter matter, 
however, the mechanical dentist should himself know all about; it 
is not a necessity that the surgeon particularly heed it. Finally, the 
plates, with their rims, having been accommodated, each to its special 
requirements, the two are put at the same time in place in the mouth. 
This done, the patient is directed to close naturally the jaws ; as 
now the rims of wax meet, and adhere to each other, the natural 
bite or articulation is secured. The operator now, with a knife, 
or other convenient instrument, marks from plate to plate upon the 
united rims of wax, a mark which represents the exact centre 
of the mouth, and besides this central mark two others, one upon 
either side. The plates may now, in their united condition, be re- 
moved from the mouth, and are ready for another transfer. If, bow- 
ever, it happens, as indeed is not unlikely, that in removing the 
plates they have separated, it makes but little difference, as by the 
lines which have been made they may at any moment be replaced 
in the original relation. 

Peculiarities in articular relations occasionally present, the man- 
agement of which requires experience to make easy. As an ex- 
ample, reference may be made to a condition in which teeth 
remaining in both the upper and lower arches hold such mutual 
relation that in the closure of the mouth they pass each other, 
allowing thus the teeth of either jaw to strike the gum of its antago- 
nist. Proper articular relation here resides in so arranging the 
artificial teeth that the bite is restored to the original plane. In 
other words, in the arrangement of the wax, the closure of the jaw 
is to show the impression upon the wax on that plane which would 



ARTIFICIAL DENTURES. 477 

be natural, should the irregularly placed teeth strike instead of 
passing each other. 

In an attempt to procure almost any but the most simple of ar- 
ticulations, the operator finds himself annoyed by false bites, the 
patient closing his mouth in every way but that which is the right 
one ; and most particularly has experience shown this to be a result 
where special pains are taken to instruct a patient as to the 
manner of the closure. A proper bite, it is to be recognized, is the 
natural one. After arranging the wax, tell the patient to close the 
mouth. Having thus obtained an articulation, take the piece out, and 
after a few minutes replace it ; procuring now a second bite, should 
both correspond, the inference may be in favor of correctness. 
Should, however, a different impression be made upon the wax, one 
or the other of the bites is necessarily wrong, and the test is to be 
repeated until satisfaction is secured. 

Articulating a Denture. — When an articulation, or bite, as 
just described, is faultless, the relations of an artificial denture 
should be equally perfect. It very frequently happens, however, 
that, from fault either in the surgeon or the artist, the desired 
and absolutely necessary perfectness of occlusion does not exist, 
certain teeth being seen to strike unduly, thus denying a common 
occlusion ; or it may be that the cusps are found wrongly placed 
as regard is had to their articulating neighbors. 

To appreciate the character of a proper articulation, the reader 
will refer to Fig. 1, also to description, page 109. 

Integrity and mechanical adaptability in articulation are essentials 
to usefulness and comfort. Artificial teeth which do not strike 
properly can never be of service or good to the wearer. When, 
therefore, a finished set of teeth are found in this direction to be 
so far out of the way as not to permit of satisfactory correction, the 
very best thing is to begin again, and have them made over. Such 
a necessity must come more or less frequently to the inexperienced ; 
each mistake, however, has in it the compensation of a lesson more 
instructive than a dozen successes. 

Artificial dentures slightly false in articulation constitute the 
rule rather than the exception. Relief here is found in recognizing 
the false touching points, and by the use of the corundum stick, or 
preferably the lathe (see Fig. 191), cutting them away. 

Closing his own teeth, one recognizes a solidity and regularity of 
occlusion. This is the whole secret of articulation. No tooth is to 
touch before its fellow: the bite is to be common. 



CHAPTER XXL 



IRREGULARITIES OF THE TEETH. 



Teeth irregularly related to the common arch are, under favor- 
able conditions, capable of having the malposition corrected without 
ill results. 

Conditions to be appreciated are : 1st, general and local health; 
2d, age of patient ; 3d, nature of alveolar process. 

A patient laboring under dyscrasia, or one of extreme nervous 
temperament, will scarcely be found a proper subject for the endur- 
ance of details necessary for the correction of misplaced teeth: the 
first, by reason of a degenerating inflammatory action almost certain 
to be provoked ; the second, because of nervous excitability aroused, 
which involves a risk to the health at large, of greater import than 
any local good which may result. 

A patient over twenty-five years of age may, as a rule, be deemed 
to have attained to a solidity and fixedness of stature which render 
the risk of change overbalancing the promise of good. The period 
intervening between twelve and seventeen years of age is found by 
experience to be the time of election for this class of operations. 

An alveolar process of loose structure is more capable of affording 
response to a mechanical impression than is one of solid character. 
In the first, a tooth may be quickly changed in its position ; in the 
second, not only is more time required, but great increase in the 
moving force. 

Treatment which pertains to regularity and harmony in the 
second denture commences with the first, the rule being that a 
deciduous tooth is not to be extracted, save by compulsion, until a 
successor is ready to take its place. (See Anomalies of Dentition.) 

A tooth is changed in its position by the application of force 
drawing in the required direction. The physiological changes in- 
duced in the enveloping process are, first, absorption of the parietes 
of that aspect of an alveolus pressed upon ; second, the exudation and 
organization of plasma in the part relieved. Change too rapidly 
(4*8) 



IRREGULARITIES OF THE TEETH. 479 

effected excites inflammation, or otherwise draws the tooth from its 
cavity; haste in the correction of an irregularity is never safe. 

In orthodontia, as in every other department of surgery, familiarity 
simplifies practice. To move teeth, but few means are really requi- 
site. Complexities in appliances are commonly found to signify lack 
of true skill. 

A full consideration of the associations of a case is to precede 
operation upon it. Such consideration embraces, first, age. Asa 
rule, it will not be found good practice to attempt the moving of an 
undeveloped tooth, the parts being too susceptible and irritable. 
(See Dentition.) Second, condition. Not only are the dyscrasic 
and nervous conditions adverse to operation, but more immediate 
expressions are also to be taken into account. Teeth, from the 
shape and direction of their crowns, are sometimes to be recog- 
nized as possessed of peculiarities of fangs, which, in a proposed 
change, must compel the piercing of the alveoli. Again, teeth of 
bulky crown may have stumpy roots of such limited relation to 
their alveoli that very slight traction will drag them from their 
sockets. A tooth out of the arch may be a supernumerary ; or it 
may in every respect simulate the true teeth and yet not belong to 
the regular denture. 

The inferior anterior teeth of the second set are in nearly all in- 
stances found more or less irregular in the manner of their eruption, 
if not unduly crowded from narrowness of the arch; it will be the 
exception, however, where they will not prove self-correcting. Also 
is it found the case that in nearly every instance where accommo- 
dating space exists, irregularly developing teeth, wherever situated, 
will of themselves seek proper relation. Early interference is there- 
fore, because of such natural tendency to self-correction, to be 
deprecated, except where it is evident that mechanical relations 
render such self-correction impossible. A single example may illus- 
trate. Let a case be supposed where the superior central incisors 
develop with their cutting faces so inclining inward, that in occlu- 
sion of the jaws the inferior teeth close against the labial surfaces : 
here it must be seen that time, instead of serving to correct the de- 
formity, will only increase it. In such an instance, a correction 
as immediate as possible is desirable. Judgment must direct the 
means and the manner: the superior teeth should certainly be placed 
outside of the inferior: if it is done without provoking inflammatory 
resistance, however accomplished, the means employed have neces- 
sarily been judicious. (See illustrative cases.) 



480 ORAL DISEASES AND SURGERY. 

Instances, again, are met with where certain teeth have com- 
pletely changed position: a lateral incisor appearing in the situa- 
tion of the central, the central occupying the place of the lateral. 
Here there is no correction possible, except it be found in extraction 
of the teeth and their rearrangement upon a plate, or through the 
pivoting process. 

• Teeth irregular to the arch, and held in the false position only 
by pressure from the articulating teeth, find easy correction ; forced 
into proper place, the same teeth which continued the deformity 
will prove the instruments of permanency to the new relation. 

The apparatuses used for correcting irregularities are to be as 
delicate as regard to a necessary strength will allow : they are to 
permit of ready change of form or relation to suit the constantly vary- 
ing requirements of cases ; the construction and application should 
be as simple as practicable, that thus, as much as possible, the 
assistance of the patient be engaged ; they are to be easy of removal 
and replacement, that thus a necessary cleanliness be secured. 

In the relation of plates to the necks of the teeth, care is to be 
exercised that unduly sharp edges shall not cut the enamel ; while 
in the employment of gum rings, now in most common use, atten- 
tion is demanded to the avoidance of injury to the gums so apt to 
ensue from the sliding up of the ligature, a result easily avoided by 
placing between the gum and ring a thread of waxed silk tightly 
tied around the tooth. 

Teeth changed, through mechanical means, in position, are to 
have support in the new location until the required alteration is 
effected in their alveoli. This support is most commonly seen to 
be given by nature : as for example, where a tooth being inside of 
the arch and so retained by the overlying teeth, being forced out- 
side, is equally compelled to retain the new place by the pressure of 
the very same teeth. In all cases, however, where circumstances 
deny natural support, advantage is to be taken of mechanical ap- 
pliances ; such appliances being found in ligatures, metal bands, or 
plates. 

With such appreciation of the simplicity of the principles under- 
lying the practice of orthodontia, a few illustrative cases in prac- 
tice may be presented as hints to the ingenuity of the practitioner. 

Illustrative Cases. — Fig. 195 exhibits a cast taken from the 
living mouth, in which, as is seen, the bicuspidati and lateral incisors 
approximate. Age of patient, ten years. 



IRREGULARITIES OF THE TEETH. 



481 



Studying this case, it becomes recognized that a required space is 
absent, namely, that for the accommodation of the cuspis of either 
side. At eight years of age, the incisor found its place ; at nine years, 
the bicuspis. Most important was it that the space occupied by the 
deciduous cuspis should be preserved by the retention of that tooth 
until the eleventh year, the period of eruption for the permanent. 
Not preserved, the room naturally became occupied by adjacent 
teeth ; hence irregularity was inevitable : unless, indeed, it should 
have happened that the second cuspis remained unerupted, — a matter 
which must always necessarily occasion more concern than even a 



Fig. 195. 



Ftg. 196. 




deformity. Fig. 196 exhibits a front view of a similar mouth, the 
cast being taken in the fifteenth year, four years after the eruption 
of the cuspidati. This irregularity is the one most frequently to be 
met with. 

Treatment. — If an arch so presenting exhibits a proper articula- 
tion, — that is, if the bite is as described on page 109, — then a practice 
lies between the removal of the projecting cuspidati, and that of the 
immediately adjoining bicuspidati. 

As facial expression is concerned, it is to be remembered that 
much of character resides in the eye teeth. Many mouths from 
which these teeth have been removed possess a flat, expressionless 
appearance, most undesirable. Again, it is found that these teeth 
serve as keystones to the arch : hence it frequently follows that 
secondary irregularity associates with their removal. 

Where a mouth with overriding eye teeth possesses proper articula- 
tion, — that is, where the superior incisors fully override the inferior; 
where the bicuspidati resemble in their labial outlines the cuspidati, 
and where the approximation of these teeth with the lateral incisors 
is complete and regular ; where the cuspidati are situated well for- 
ward, and not over the bicuspidati, or even over the interspaces ; 
where the patient is advanced in years, the process having become 
fixed in its relations: it is, in a case of this kind, the proper practice 

31 



482 ORAL DISEASES AND SURGERY. 

to extract the eye teeth. On the contrary, where the patient is 
young, where the articulation is harmonious, where the projecting 
teeth are situated over the interspace, or, still better, posterior to 
it ; where the bicuspidati do not simulate in appearance the cuspidati : 
the practice proper to be pursued consists in removing the under- 
lying premolars. Here, however, arises a question. The anterior or 
six-year molars, of all teeth in the mouth, excepting perhaps the 
dentes sapientiae, are the most frequently found decayed. If these 
teeth are seen to be carious beyond the ability of cure, and if the 
first or underlying bicuspidati are sound and healthy, will not expe- 
rience indorse the saving of these latter teeth and the extraction of 
the diseased organs? 

Experience exhibits that the developing tendency of the teeth is 
always in a forward direction ; the extraction of a first molar does 
not favor to any extent the accommodation of the cuspis: the second 
bicuspis will not fall back into the space made. On the contrary, a 
second irregularity is favored in the immediately manifested inclina- 
tion of the second molar to fall obliquely forward, thus breaking the 
harmony of the grinding relations. 

The preservation of the first molar teeth is of great importance to 
the usefulness of a denture. It is a great misfortune where they have 
been neglected.* 

A third condition of this special deformity is met with where it 
is evident that the slightest curtailment of the arch would destroy 
the harmony in articulation, — that is, the overriding is so slight that 
the extraction of two teeth might possibly result in the anterior 
teeth closing directly upon each other, or perhaps, indeed, in the 
inferior teeth closing outside. Two lines of practice here present. 
The bicuspidati may be removed as before directed, and by the em- 
ployment of an occipito-mental elastic sling, exhibited and described 
on a succeeding page, the inferior arch may be retracted ; or the 
superior arch may be enlarged to an extent which shall afford the 
required space through the aid of instrumental assistance ; or, still 
again, equality may be maintained by the extraction of correspond- 
ing bicuspidati from the lower jaw. 

* The inferiority of the first molars is fully recognized. Mr. Tomes sug- 
gests the removal of these teeth under the circumstances we consider, founding 
his practice on the following statistics: "Under the age of fifteen the re- 
spective liability to loss from caries runs in the following order : central 
incisors, 2 per cent. ; lateral incisors, Sh per cent. ; canines, 1\ P er cent. ; first 
bicuspids, 7 per cent. ; second bicuspids, 8J per cent. ; first permanent molars, 
68^ per cent." 



IRREGULARITIES OF THE TEETH. 



483 



Of appliances used in the correction of irregularities, every variety 
is to be found. The operator will always, however, find himself 
best served in employing the most simple means capable of meeting 
indications. 




Fig. 191 represents an appliance devised by Dr. J. D. White, the 
office of its mechanism being the enlargement of the whole superior 
arch and the consequent accommodation of any outlying tooth or 
teeth. Taking an impression of an arch, a plate, in shape as shown, 
A, is made ; this plate, separated into two parts, has its association 
preserved by a spiral spring, C, so arranged as to lie directly back 
of the teeth, being thus as much out of the way as possible. B 
represents crib bands for attachment to the first or second molar 
teeth, as may seem advisable. D, a hinge, joins the parts in front ; 
a device, however, which, for the purpose now considered, is to be 
replaced with advantage by any arrangement admitting of lateral 
separation on the line of division. It is to be recognized that in the 
tendency of the spring to straighten itself the plate is separated, 
outward pressure being thus exerted against each tooth. 

A second appliance, having similar import, shown in Fig. 198, is 
the device of Dr. A. Westcott. This 
apparatus, as must be appreciated, 
possesses in its construction the 
ability to move outwardly any tooth 
or teeth requiring change of posi- 
tion. The instrument may thus be 
described : First, a double clasp 
(A, A), these clasps connected to- 
gether by a straight bar made of 
tubular wire. This tube has a screw cut in its inside the whole lenjrth. 




484 ORAL DISEASES AND SURGERY. 

and is soldered to one pair of the double clasps ; the other pair of 
clasps are soldered to a wire which screws into the tube, the object 
being to lengthen or shorten the bar at pleasure. Next a flat piece 
(C, C) of sufficient width for hinge-joints is soldered to the bar. To 
these are connected by hinge-joints (F, F, F, F) a series of tubes 
(D, D, D, D), each having a screw cut on the inside, these receiving 
and accommodating an equal number of spurs (C, C, C, C). These 
spurs, as is recognized, screw back and forth as may be desired, and 
are therefore capable of pushing (in time) any tooth from its socket. 

Such an apparatus prepared, the clasps are slipped about the teeth 
for which they have been adapted, and, slight depressions being 
reamed upon the posterior faces of such teeth as it is designed to 
move, the spurs are screwed forward, the point of each thrusting 
upon the depression prepared for it. 

Examining the construction of this piece of mechanism, its peculiar 
adaptability to the end designed must certainly strike any one ; a 
single weak point being the reamings used as supports to the spurs, 
— an objection which may, however, in many instances, be obviated 
by receiving the spur between a double ligature of gilling or book- 
binder's twine. 

The moving of the teeth accomplished, the apparatus may at 
once be removed, the parts being maintained in their new position 
by fitting a plate covering the whole roof of the mouth, acting 
like a wedge in its relation to the common arch. Fig. 211 exhibits 
such a retaining plate. 

Still another means of enlarging an arch to afford room for 
outlying cuspidati consists in adapting to the lower denture an 
accurately-fitting envelope of metal, from the articulating face of 
which pass upward and inward springy flat spurs, against which, 
in the act of occlusion, the superior teeth close, thus being directed 
outward, and to such extent spreading the parts. A spur, of course, 
is not to strike either of the eye teeth. 

Passing here to another study, a case may be presented where, 
with room in the arch, the lateral incisors maintain a posterior posi- 
tion. 

Fig. 199 exhibits such a condition. This is an irregularity capable 
of quick correction, as exemplified in the use of the bar (Fig. 200). 
This bar, being adapted to the labial face of the teeth, is held in 
position by silk ligatures bound tightly to the misplaced teeth. A 
great improvement on the silk, however, as has been shown by Dr. 
J. H. McQuillen, consists in the substitution of india-rubber rings, 



IBREGULAR1TIES OF THE TEETH. 



485 



applied, as will be understood by referring to the diagram, by being 
slipped into the holes through file cuts made from the face of the bar. 



Fig. 199. 





Another study is presented in Fig. 201. Here, it is seen, a central 
incisor is out of the arch. To correct this deformity a very common 

Fig. 201. 




and very satisfactory practice is that exhibited. This consists in an 
india-rubber ring thrown about the projecting tooth, being stretched 
back until it reaches a bicuspis, around which it is placed. In thus 
employing the elastic ring, it will not unfrequently be found that 
undue strain is exerted upon the base-tooth, making it quickly very 
sore. In these cases the ring is to be changed to other teeth, or 
assistance may be rendered by relieving the first tooth of an excess 
in strain by dividing the work by means of a ligature carried to 
some back tooth. 

Fig. 202, a case from the practice of Dr. J. Foster Flagg, exhibits 



486 



ORAL DISEASES AND SURGERY. 



another deformity. Here, as is seen, irregularity exists in both 
arches. " The treatment consisted in removing all the second bicus- 

Fig. 202. 




pids, above and below, and throwing india-rubber tubing ligatures 
around the six-year molar left inferiors, and the left inferior first 
bicuspid and cuspid, drawing the two latter backward into the arch, 
at the same time passing a silk ligature around the lower incisors 
(Fig. 203) in such manner as to force into position an overlapping 



Fig. 204. 



Fig. 203. 




central. In the upper jaw a plate (not a necessity) was adapted to 
the palate, secured by silk ligatures to the first permanent molars. 
Pins were placed in the plate in such manner as to allow of the 
attachment of two elastic bands, which were secured by silk threads 



1RBEGULARITIES OF THE TEETH. 



487 



to the central incisors (Fig. 204), drawing upon the mesial face. 
Other bands were so arranged as to draw upon each lateral angle of 
the centrals, passing between the centrals and laterals from their 
palatine faces, and running along the labial and buccal faces unto the 
first molar of either side. Tubing was thrown around the remaining 
superior bicuspid of either side and the molar, for the purpose of 
approximating these teeth, thus affording space for the proper placing 
of the irregular centrals. By this arrangement, nine ligatures were 
exercising traction at the same time, gradually and beautifully per- 
forming their work of correction (Fig. 205). With the view of pre-' 

Fig. 205. 




venting periosteal irritation from becoming periostitis, both local and 
constitutional treatment was adopted, as the exigencies of the case 
seemed to require. Gentle purgatives, as derivants, and tinct. aco- 
niti rad., were used; chlo. potas. and plumb, acet. as local antiphlo- 
gistics, and solution of aqua ammo. con. as an antacid. The cure 
was effected in just two months, and, as the patient averred, with- 
out any pain or inconvenience worth mentioning." — Description by 
operator. 



Another study, to which attention may be directed as being a 
quite common condition, resides in that articulation in which the 
anterior teeth of the superior jaw, in place of overriding the inferior, 
close directly upon them. This manner of bite, when found in 
elderly persons, is not to be remedied by any change in the position 
of the teeth, but by the adoption of some mechanical device, which 



488 



ORAL DISEASES AND SURGERY. 



Fig. 206. 



shall relieve the organs of the abrading influence to which they are 

subjected, and which, unrelieved, will wear them to the gums. 

To treat such a malarticulation, three 
modes have been employed : one con- 
sisting in a metal cap inclosing the molar 
teeth, this keeping the anterior teeth 
apart and taking the strain of mastica- 
tion ; a second, a cap to be worn over 
the front teeth while eating (Fig. 206) ; 
and third, the cutting of cavities in the 

antagonizing faces of the abrading teeth, and building thereon faces 

of gold. 

Fig. 207 exhibits a malarticulation known as "underhung," — 




Cap for Front Teeth. 



Fig. 207. 




the teeth of the lower arch closing beyond the upper. To correct 
such a deformity, different operators employ different means. Such 
a case presenting, a first consideration is as to the nature and cause 
of the condition. 

Protrusion of the inferior teeth may exist from a variety of causes. 
The jaw itself may be elongated, the angle being too obtuse for the 
age. The body of the lower jaw may be out of proportion to the 
upper. The teeth themselves may unduly spread or evert. The 
fault may be in the superior denture. 






IRREGULARITIES OF THE TEETH. 



489 



Fig. 208. 




An anatomico-physiological examination of the inferior maxilla 
exhibits a body and ramus whose 
angle of relation varies with the 
age of the patient, or some other in- 
fluencing circumstance. At a very 
obtuse angle in young life, it passes 
to the right angle in adult life, to 
fall again into the obtuseness on 
the approach of old age and the 
loss of the teeth. The three speci- 
mens (Fig. 208) represent these 
varying conditions, — the first, the 
infant bone, being very obtuse; the 
second, the adult, being at a right- 
angled relation ; the third, the bones 
of an edentalous old person, having 
the ramus almost on a plane with 
the body. 

In a young patient having a 
protruded under jaw, the size of the upper jaw and the position of the 
teeth being normal, advantage is to be taken of the natural tendency 
of the parts to retire; a sling, — the occipito-mental, — the straps 
being of elastic material, is to be used, as represented in Fig. 209. 
Such a sling, properly made and applied, will be found to exert such 
constant pressure on the angle, forcing, as it does, the body back- 
Ward, that not unfrequently a very few months will suffice to correct 
such a malarticulation, and this without discomfort or the possibility 
of ill consequences. 

Where fault resides in the superior arch, the jaw itself being small, 
or the teeth being possessed of inlooking cutting faces, the appliance 
represented in Fig. 209 may be used, or the envelope, with the flat 
spurs, may be employed, as directed for use upon the lower denture 
(Catalan's inclined plane). 

A mode of treating a case of malarticulation such as is exhibited 
in Fig. 207 — this cut being indeed a model taken from this special 
mouth — has been practiced after the following manner with a suc- 
cess as exhibited in Fig. 210, by Dr. Norman Kingsley. 

The external features of this case, says Dr. Kingsley, showed, — 

" 1st. That the lower jaw was not too large, being neither too wide 
nor too long. This determination was easily arrived at by a com- 
parison of the extreme lower part of the face with the upper part of 



490 



ORAL DISEASES AND SURGERY. 



the face and head. 2d. The same course of reasoning showed that, 
relatively, the upper alveolar border and row of teeth were con- 
tracted so much as to produce limited external deformity. 

Fig. 209. — Occipito-Mental Sling. 




" To a casual observer, the chin and lower lip were too full. To a 
more accurate observer, the upper lip, cheeks, and nose were de- 
pressed. I suggested that immediate attention would correct what 
otherwise would become an increasing deformity through life. 

" The casts as represented in Fig. 207 were taken, and the first 
fixture applied, January 19. Six days afterward the incisor teeth 
of the upper jaw were overlapping the lower incisors. 

" On that same day, namely, January 25, I gave a clinic, by pre- 



IRREGULARITIES OF THE TEETH. 



491 



vious engagement, under the auspices of the District Dental Society 
of New York, on the subject of ' Treatment of Irregularities,' and 
I took an impression and made a cast of this case, exhibiting it there 
as a part of my demonstration, to prove the rapidity with which 
teeth could safely be moved into certain positions. 

" Within twenty days from the time the power was first applied to 
the teeth, the entire upper row was articulating outside of the lower 
ones, substantially as shown in Fig. 210. A retaining plate was 

Fig. 210. 




Fig. 211. 



adapted to the upper jaw, such as is shown in Fig. 211, which was 
worn, with some unimportant modifications, for several months. 

"The result is a most marked 
change in the profile, and in the 
relation of the external features. 
The individual features being natu- 
rally well formed and symmetrical, 
the change in their relations pro- 
duced a face of more than usual 
beauty. 

" The treatment consisted solely 
of wedges inserted between the 
teeth, as shown in Fig. 212, in con- 
junction with the retaining plate, 

Fig. 211. Wedges were inserted between all the teeth, and worn 
from the first. These wedges were of elastic rubber, and used 
of such thickness only as would exert a gentle pressure. The 




492 



ORAL DISEASES AND SURGEBT. 



retaining plate answered a twofold purpose : first, it kept the teeth 
from the possible contingency of any one of them moving toward 



Fig. 212. 



: r ^ 



r , 




the centre of the mouth ; and, secondly, — what was of equal 
importance, — points of the retaining plate were allowed to pass 
between all the teeth, which kept each wedge from slipping up into 
and irritating the gum. 

" The patient was watched daily so long as the wedges were acting. 
When, by reason of their want of thickness, they ceased to act, new 
ones, but slightly thicker, were substituted. There was no more 
discomfort to the patient undergoing this process than is commonly 
experienced in the wedging of one or two teeth in the mouth for the 
purpose of getting space for filling. There was no soreness which 
called out complaint from the patient. There was no favoring 
diet, nor was there any provision made for masticating while the 
teeth were in transit. 

" The teeth in their new position and articulation, as seen in Fig. 
210, have remained stationary now for a period of three-quarters of 
a year. Not only is the external face improved, but a longevity is 
guaranteed to these teeth by their isolation which could not have 
been obtained by any other means. 

" The foregoing statement is not put forward as the report of a case 
to prove what is sometimes possible, or what trials nature may un- 
dergo and still survive, but it is set forth as an illustration of a prin- 



IRREGULARITIES OF THE TEETH. 493 

ciple in the treatment of irregularities which has never before been 
published. I have heretofore claimed something for aesthetic art in 
the practice of dentistry ; for the above I claim nothing but a recog- 
nition of pure mechanical principles in dental practice. The wedge 
is one of the recognized mechanical powers. Its application here is 
identical with its use by the architect for a keystone in building his 
arch. Drive in the keystone, and the arch is necessarily enlarged, 
and will continue to be enlarged so long as a wider keystone is ad- 
missible and there is a support which will prevent the whole arch 
from tumbling in ruin to the centre." 

In attempting the correction of a deformity as here suggested 
by Dr. Kingsley, special regard would necessarily have to be had 
to the more immediate results. Without doubt the wedge is a most 
important means to the correction of an irregular denture, but it is 
an agent capable of doing so much harm through the irritability it 
provokes, that the cases must be few indeed in which it could be 
so largely made use of as in the instance just considered. This par- 
ticular case is employed, however, as an illustration, not that it may 
be commended to the inexperienced, but rather to exhibit what judg- 
ment, aided by the most simple of appliances, may accomplish. 

A very simple and not unfrequently effectual mode of correcting 
the deformity of protruding lower teeth in young patients, applica- 
ble particularly where the organs close directly against each other, 
consists in removing from the inferior arch the first bicuspidatus of 
either side, which begets in the patient a habit of pushing the chin 
backward ; or the latter purpose will be answered by wearing the 
occipito-mental sling during mealtime. 

Among the various appliances which ingenuity has suggested for 
the treatment of dental irregularities, is a plate devised by Dr. Red- 
man, of Cincinnati. This is a rubber cap accurately fitting the pala- 
tine arch and carried across the anterior face of the teeth, having 
thus, as is seen, a most secure relation. Where it is desired to move 
a particular tooth, the plate is cut away in the direction which it is 
desired the tooth shall take, pressure being brought to bear from the 
opposite point by wedges of wood forced through holes in the plate. 

In correcting irregularities of the teeth, it is always necessary to 
bear in mind the antagonism which may exist to the moving force 
as relation is had to the articulation. A tooth bound in place by one 
overlying may only be moved through relief from the existing 
pressure. To insure such relief it is found necessary, in almost all 



494 ORAL DISEASES AND SURGERY. 

cases, so to cap neighboring teeth as to compel a space between the 
two arches, — such space to be preserved until the tooth is changed 
to its new position, when the removal of the cap and the restoration 

of the articular bite will, in many 

• FlG - 213, instances, prove the best means 

%v 13a ((T that can be adopted for securing 

nF^^^5^^QHSS^^^^yl permanency to the change. Fig. 

W Til 213 represents a principle found 

Jr • ^L=» most useful in a great variety of 

cases of dental irregularities. An 
example of its application may be given as follows : 

Case. — Two central incisors turned upon their axes and over- 
wrapping ; arch narrow and crowded. — To turn teeth so situated, 
a first necessity is room. To secure this room the arch must be 
widened. Examination of the instrument exhibits double collars 
for resting against teeth on opposite sides of the arch : these collars 
are attached to screw-cut tubes 1, 2, which tubes are associated by 
a common screw, 3. Desiring to widen the arch and thus afford 
facility for manipulating the crowded incisors, the collars are placed 
against the inner faces of the teeth designed to be moved, when, 
by means of a wrench, the screw is turned, the arms being extended 
day by day as circumstances permit. The desired space thus secured, 
a plate is fitted to insure retention of the teeth in the new position, 
when the teeth may be turned into proper position, as practiced 
in the example from Dr. Flagg. 

Illustrating the use of this means in another instance, reference 
may be made to lateral incisors, or other teeth fallen within the arch 
and overlaid by their fellows. Here application of the enlarging force 
is made in the same manner. When the proper room has been 
secured, the misplaced tooth may with all facility be drawn into 
place by the labial plate and elastic ring, as before described, a 
manipulation which would be impossible without the previous 
expansion. 

Repeating to the reader the conviction that the principles of or- 
thodontia are of much more consequence than a knowledge of special 
appliances, the subject may be left with assurance that the illustra- 
tions given are all that can be needed to afford the requisite hints 
for the government of such special or peculiar cases as may from 
time to time be met with. 



CHAPTER XXII. 



DISEASES OF THE TEETH. 



SALIVAKY CALCULUS. 



Salivary Calculus, or tartar, as it is commonly called, is that 
limelike material so often seen collected about the necks of the teeth. 
Observation elicits the fact that the primary seat of deposit is about 
the posterior or lingual faces of the inferior central teeth and the 
buccal aspect of the superior molars ; and as in these situations 
exist the outlets of the salivary secretions, the inference is that from 
such secretions comes, in part at least, the deposit. 

Analysis of Saliva. Analysis of Salivary Calculus. 

Water. Carbonate of lime. 

Ptyalin. Phosphate of lime. 

Pat. Pat. 

Chloride of sodium. Mucus. 

Chloride of potassium. Accidental matter. 
Phosphate of lime. 
Sulpho-cyanide of potassium. 

When the salivary secretions are sluggish, the inorganic material, 
not being held in solution until fairly ejected into the mouth, becomes 
deposited about the roughened and inviting surfaces of immediately 
neighboring teeth. A nucleus once fairly formed, aggregation goes 
on, until serious secondary lesions are apt to result. 

The first and most marked effect of salivary calculus is upon the 
teeth themselves ; beginning upon one face, it soon involves the 
whole organ, and, if undisturbed, envelops, sooner or later, in an 
imperfect sheath, the whole denture. A mouth so filled with tartar 
is not only disgusting, but necessarily also in an unhealthy con- 
dition. Salivary calculus soon destroys the integrity of the teeth. 
It does this by its effects on the secretory crypts about their necks 
and by compelling the gradual diminution of the periosteal supply ; 
this membrane dying little by little as the foreign bod}^ encroaches 

(495 ) 



496 ORAL DISEASES AND SURGERY. 

on it. As a result of such abstraction of nutrition, the tooth soon 
dies, and is exfoliated like any other sequestrum ; tooth after tooth 
necrosing, and each month or year one or more dropping from its 
socket. 

Not unfrequently there may be seen standing, isolated and alone, 
on some portion of the dental arch, — most frequently, however, 
either on the anterior portion of the inferior arch, or the posterior 
portion of the superior, — a yellowish-looking tumor, which might 
not inaptly be compared to a shellbark covered with inspissated 
mucus. Sometimes this tumor will be found quite firm in its po- 
sition, seeming, indeed, as if it might have sprung from the socket 
of some long-ago-extracted tooth ; at other times you will be able 
to move it quite freely, as if it had a fleshy peduncle. These tumors 
give to the patient a most disagreeable appearance, are oftentimes 
insufferably offensive, and so detrimental to health that five or six 
grains of their substance, given to a small animal, will not unfre- 
quently cause its death. The composition of such tumors consists 
of phosphate and carbonate of lime, epithelial scales, inspissated 
mucus, and the various detritus of a cavity devoted to mastication. 
In other words, they are calculi. The nucleus of such growth is of 
course a tooth. The manner of formation is too evident to need 
description. I have removed these calculi, where the nucleus had 
become so encysted, from crown to apex, that no trace of it was to 
be discovered without dividing the mass. Where, however, the 
encystment has advanced to this extent, the tumor is about ready 
to drop from the mouth. I have seen a calculus of this kind encyst 
the six lower front teeth, making as strange a looking tumor as 
could be well imagined. 

Similar calculi develop, as may be inferred, in other parts of the 
mouth. Thus, just within the orifice of the duct of Steno they may 
occasionally be found ; the tumor, in such a case, bulging out from 
the cheek against the second molar tooth of the upper jaw. The 
formation of such tumors in these situations does not necessarily 
imply the closure of the orifice of the duct: they form when the 
gland is sluggish ; the secretion not being in sufficient abundance to 
hold the lime of the saliva in solution until it is ejected from the 
duct, it falls on the floor of the duct, aud, lodging, makes the 
nucleus. 

I remember, on one occasion, having been called by a fellow- 
practitioner to see a case where a mass of this calcareous matter, 
fully the size of the largest almond, seemed to be growing from all 



SALIVARY CALCULUS. 497 

that portion of the sublingual region anterior to the gland of that 
name ; one-half the tumor looked as if it might be below the level 
of the floor of the mouth, the mucous membrane enveloping the mass 
with ragged and ulcerated edges. It certainly presented a very 
strange and threatening look. My friend was deceived as to its 
character, because there was no apparent direct association between 
the tumor and the neighboring teeth, and because it was as firmly 
fixed as though it might have been a growth springing from neigh- 
boring bone. Yet this was a salivary calculus and nothing else, the 
only question being as to its cause and fixedness. 

Looking about the mouth, I perceived that the patient had certain 
artificial teeth on the left side of the arch ; these teeth were all coated 
with tartar, and so associated thereby with the natural teeth as to 
be only distinguishable by that difference in the translucency so 
immediately noticeable by any one experienced in such direction. 
Knowing well that it is a plan with many dentists to secure such 
teeth by passing a strong gold wire across the mouth, and which 
wire not unfrequently buries itself within the mucous membrane, 
thereby occasionally becoming concealed, I inferred at once that this 
would be found the nucleus of the calculus, and accordingly so 
directed an examination. This was commenced by cutting away 
the calculus from about the artificial teeth, and, as anticipated, the 
band was revealed ; next was sought the concealed attachment of 
the opposite side, and this being discovered and exposed, the two 
ends were forced from the teeth which they clasped, and thus the 
artificial teeth, wire, and calculus were lifted from the mouth in a 
body. 

The site of the calculus, as may be inferred, presented a cup- 
shaped ulcerated depression, and was quite angry-looking. 

The only after-treatment consisted in the use of an astringent 
wash. The ulceration healed kindly in a very few days. 

It may be suggested that the existence of such calculi is not an 
unfrequent cause of dyspeptic and other alimentary troubles. I 
have just now in my mind the memory of a case of dyspeptic con- 
sumption very illustrative. 

In her mouth, the patient, a lady, had but a single tooth, and 
this for years had been so imbedded in salivary calculus as much 
more to resemble a half-rotted shellbark than a tooth, — her breath 
was made insufferable by it. I removed the offensive mass, and the 
recovery of the patient was really magical in its rapidity. 

Such calculi are to be removed in any convenient manner : they 

32 



498 ORAL DISEASES AND SURGERY. 

may be pulled away, broken in pieces, or, when loose, may be cut 
from the gum ; the operation being entirely a mechanical one, and 
of course very simple. 

I forget, however, in such advice, reference to calculi situated in 
the salivary ducts. These are to be removed, either by enlarging 
the orifices and crushing the stones, or by cutting down upon them 
at the most convenient point. When so cut upon, the wound will 
not commonly require any after-attention. 

The existence of salivary concretions in the ducts, particularly the 
Whartonian, is not at all unfrequent ; indeed, they are occasionally 
to be met with in the substance of the glands themselves. A 
specimen, extracted from the submaxillary gland, had its diagnosis 
in a continuous issue of pus from the tubal outlet. A second instance 
is on record where the glands of either side were found stuffed with 
calculi. When situated in the ducts, the sense of touch, exhibiting 
the hardness and irregularity of the body, will not unfrequently 
afford recognition of the condition. Where, however, the enveloping 
tissues have become infiltrated and thickened, a diagnosis by such 
means is rendered obscure, and is perhaps to be secured only by 
passing into the tumor the point of a delicate bistoury, or the ex- 
ploring-needle. 

In the case of a calculus in the substance of the submaxillary 
gland, met with by the author in his own practice, a happy cure 
was effected by working the stone to a presentation upon the floor 
of the mouth, secured by depressing the chin upon the neck and 
thrusting the gland from without upward. Knowledge of the exact 
position thus secured, a single cut, passing through the mucous 
membrane and mylo-hyoideus muscle into the substance of the 
gland, reached the body, which, with some little trouble, was se- 
cured in the grasp of the forceps and removed. In size this 
calculus was about the circumference of a hazel-nut. The wound 
made healed completely after a week, and the patient had no future 
trouble. 

An interesting and most suggestive case in this direction has the 
following record : 

Mrs. Boyd, a lady, sixty-nine years of age, residing on Sansom 
Street, West Philadelphia, applied to the author, being directed by 
some unknown professional friend, concerning a tumor of the mouth, 
from an inflamed condition of which she was at the time enduring 
much suffering. 

Ocular inspection revealed the following condition: a tumor, 



SALIVARY CALCULUS. 499 

very scirrhus-like, hard, lobulated, and angry-looking, occupied all 
that portion of the floor of the mouth to the right of the mesial line ; 
general inflammation of the whole oral cavity, to such extent as to 
make mastication too painful to be practiced, and to render deglu- 
tition very difficult. All the teeth in the neighborhood loose, and 
occupying irregular positions, — the result evidently of a hyperplastic 
condition of the alveolo-dental membranes. The superficial cervical 
glands, especially those of the submaxillary region, sympathizing to 
a considerable extent ; while the submaxillary gland itself was so en- 
larged as to render it sufficiently prominent to be easily mapped out. 

The patient seeming unable to talk of anything except her present 
great pain, which she described as cutting, tearing, burning, the case 
was dismissed for the day, after prescribing for an immediate relief, 
— namely, the ordering of leeches, aperients combined with Dover's 
powder, astringent local applications, etc. 

Two days after, the patient was again seen. The general inflam- 
mation was resolving very rapidly, while the mental equilibrium 
was quite restored. 

This disease had been pronounced cancer by several gentlemen, 
and advice given that no application of any kind should be made ; 
that the patient should not even permit the tumor to be handled for 
any further examination. Under such impression as to its char- 
acter, the lady had given up all hope of permanent relief. 

The history of the case is as follows : 

Eighteen years before, while engaged in milking an intractable 
cow, a kick was received under the chin, so severe in character as to 
compel a confinement to bed for over two weeks. This trouble gotten 
through, the parts soon recovered their natural tone, and seemed as 
well as ever. 

But little more than nine months had passed, however, when the 
patient was made conscious of occasional slight inflammatory attacks 
about the region of the sublingual gland. These attacks continued to 
grow in frequency and extent, terminating, to use her own language, 
"by a something which looked like a whitish worm, coming from 
somewheres, into her mouth." This worm, she said, " was always 
the assurance to her of immediate relief." 

The trouble continued to recur for over a year, when a tumor 
began to develop in the parts. The inflammatory attacks now de- 
creased in number, but increased in severity, — the patient noticing 
that after each inflammation the size of the original tumor was 
augmented. 



500 ORAL DISEASES AND SURGERY. 

So the case ran on for a period of several years. It was re- 
marked, however, nearly ten years back, that the tumor had ceased 
to enlarge from the inflammatory attacks, having at that time gained 
the size of a pullet's egg, and neither increasing nor decreasing up 
to the time of my examination. Reference, of course, is made to 
the tumor in a quiescent state, for each succeeding inflammation 
swelled all the parts, tumor included, temporarily, more than the 
one which had preceded it. 

The patient's general health was quite good; there was no con- 
stitutional evidence to be perceived of a cachexia. 

Now, while the history of this tumor, in its local features, was in 
many points the history of cancer, yet, considering its location, con- 
sidering the affection of the gland duct, which, as indicated by the 
story of the worm, evidently had association with the tumor; con- 
sidering the inflammatory attacks to which the parts had been so 
frequently subjected, and which had resolved harmlessly ; consider- 
ing the length of time the tumor had existed, without passing or 
apparently tending to pass to the ulcerative stage ; considering 
these features in a diagnostic point of view, it seemed necessarily 
decided that the tumor was of local signification, and not a cancer. 

What then was it? The trouble commenced evidently as in- 
spissated ranula. My conviction, founded on the history, was, that 
it was still a ranula. Not ranula, as derivatively we understand 
the meaning of that word, but ranula, as pathologically the term 
has association with the salivary ducts. What the contents of 
such cyst, if cyst there was, might be, I did not feel prepared 
absolutely to decide. 

Acting on the strength of this conclusion, I suggested to the 
patient my impressions, and requested to be allowed to pass a 
bistoury through the parts. This, however, met with a most de- 
cided negative, — the refusal not being, perhaps, so very strange, 
considering the assurance that Mrs. B. had so often received, that 
any attempt to operate would be her death-warrant. 

Failing in several other attempts at persuasion, I became, at length, 
annoyed at the obstinacy of the patient, and dismissed the case. 

About a month after, however, prompted by curiosity, I called 
again on Mrs. Boyd. There was now not the slightest evidence of 
inflammation about the parts. The tumor w 7 as about the size of a 
pullet's egg, hard almost as stone, and distinctly divisible into 
three lobes. The patient assured me that, with the exception of an 
occasional sharp pain, she felt little or no inconvenience. 



SALIVARY CALCULUS. 501 

At this visit, more than ever satisfied in a diagnosis, an explora- 
tion was re-urged, but was as decidedly refused as before. 

On a Saturday morning I was again called to see the patient. 
She was suffering from another of the inflammatory attacks ; the 
most severe she had yet experienced. 

Examination discovered the tumor swollen to such an extent as 
to throw the tongue over into the left cheek. Mastication had been 
impossible for three or four days, while the ability to swallow was 
being very rapidly lost ; yet, with all this inflammation, there seemed 
no tendency to the formation of abscess. 

Placing the old lady in an arm-chair, before the window, with- 
out asking permission or offering any suggestion, I managed to get 
the mouth under my control, and, before she was aware of the in- 
tention, I passed a bistoury directly through the body of the tumor: 
the knife grated over some hard substance. 

After a time spent in making peace, in which I was greatly as- 
sisted by the assurance I was enabled to give of the discovery which 
was to result in her immediate cure, I proceeded to the dissecting 
out of the foreign body. This, as anticipated, proved to be a sali- 
vary calculus. The specimen was placed in possession of Prof. D. 
H. Agnew, to whom I presented it for the pathological museum of 
the Philadelphia Hospital, and is, perhaps, one of the largest on 
record. 

The pathology of such a lesion is at once appreciated : the forma- 
tion of the calculus in this region was merely secondary to the oc- 
clusion of the mouth of a gland duct. 

Dr. J. J. Woodward, who made an analysis of a portion of the 
calculus, informed me that he found it composed almost exclusively 
of the phosphate of lime, only a very small trace of the carbonate 
being perceptible. 

I saw Mrs. Boyd, for the last time, one month later. All induration 
had so completely disappeared that I think it would be difficult for 
any one who had not seen the case to say which side of the mouth 
the tumor had been removed from ; not the slightest perceptible 
tendency to disease being visible. 

A case of calculus, interesting from its rarity, has been presented 
to the attention of the French Academy of Sciences, in which a con- 
cretion was removed from a sublingual duct of an infant but three 

weeks old. The history of the case is thus given. On the , 

a poor woman called upon Dr. Burdel, complaining that the child 
could not take the breast, which she attributed to its being tongue- 



502 URAL DISEASES AND SURGERY. 

tied. Upon examination, Dr. Burdel did not discover any string or 
ligament of undue shortness, but found the sublingual gland so ex- 
cessively developed as to raise the tongue considerably from the 
cavity in which it lies. He soon discovered, by touching the tumor 
with his little finger, that it must contain a hard substance. A slight 
pressure brought to light the extremity of a calculus, ending in a fine 
point, and, after some unsuccessful attempts, he succeeded in ex- 
tracting it without an incision. The calculus is described as some- 
what of an egg-shape, but ending, as already stated, in a fine point. 
Its size was that of a grain of wheat, its color yellow, its surface 
granulous, wrinkled, and formed of a number of minute cones or 
paps, cemented together at their bases. 

This is an instance of a salivary calculus formed before the birth, 
Avhen the saliva, according to Dr. Cloquet, is but little charged with 
salts. An analysis of this concretion exhibited it as being composed 
almost exclusively of tribasic phosphate of lime and a small fraction 
of nitrogenous organic matter, which must have been mucus from 
the salivary duct. 

As seen upon the teeth, tartar varies markedly in color and con- 
sistence, being sometimes so hard and closely adherent as to seem 
almost a part of the tooth. In other instances it is found soft, and 
of such flaky nature that the slightest effort suffices to break it away 
in bulk. A character of tartar is found allied with the mucoid, or 
typh condition, being of pasty consistence, having, perhaps, a truer 
expression of its signification in the term sordes, being composed of 
detritus, combined with inspissated mucus. 

In color, tartar varies from a dirty white to black, the shade 
depending on the temperament of the individual, yet being neces- 
sarily much influenced by personal habits. In the sanguineo- 
bilious, tendency to the deposit of flaky brown tartar is very 
marked. This deposit is the truest expression of salivary calculus, 
being composed almost exclusively of the constituents of the 
saliva. 

United with all tartar are fungi. Here, as truly suggested by 
Herr Schrott, do the infusoria find convenient habitation, remaining 
the longest time, attaining their highest age, dying, and leaving 
their limy remnants to interlace with epithelial scales, parasites, 
remains of food, slime, and secretions of saliva, forming in this 
manner the tartar of the teeth : assisting to form, would have been 
the truer apprehension. 

That all tartar is not salivary calculus is made evident enough 



SALIVARY CALCULUS. 



503 



by minute examination. The deposit about the teeth of the scor- 
butic is in great part from the mucous glands situated in the mucous 
membrane enveloping the necks of the organs. Again, in mouths 
abounding in parasites, microscopic analysis shows plainly enough 
the analogy with the coral reef. Hence it is that analyses of this 
supposed common material are found so markedly and decidedly to 
differ. 

The treatment of the ordinary collections of tartar about the teeth 
is very simple, and may be made very effectual. Various cutting 
and scraping instruments, very well understood by glancing at the 
engravings, Fig. 214, are used in the process of removal. The 
operation consists simply in scraping away the mass (scaling, it is 
termed), being careful not to scratch the enamel, and afterward 
thoroughly polishing the teeth, — using for the purpose, first, pul- 
verized pumice, afterward the ordinary burnishing instruments. 



Fig. 214. — Instruments employed in removing Tartar from Teeth. 




To prevent re-collection, cleanliness is a first requirement : the 
use of acid washes, carbolic acid soap, or dentifrices, is to be directed, 
as may seem to the judgmeut of the practitioner indicated, and the 
action of the glands is to be increased, by the use either of local or 
constitutional sialagogues. Or, if in any individual case the ad- 
visability of such prescriptions might seem debatable, then pumice- 
stone, finely pulverized, may be used with a good stiff brush; or, 
what will be found a still better plan, the patient may, every few 
days, standing before a mirror, use the grit on a piece of soft pine 
or orange stick. 

Salivary calculus, lodged about the teeth, has been thought to pro- 
duce caries and necrosis of the alveolar processes. I do not, however, 
remember in my own practice ever to have seen such a result. As 



504 ORAL DISEASES AND SURGERY. 

the teeth drop out, the calculus falls away with them, and thus its 
power for evil ends. A spongy and scorbutic character of gum 
tissue, and consequent hemorrhage, are, however, very common 
associations ; but the practitioner at once sees that the cure is in 
his own hands. 

The use of acids, highly commended by some as a conclusion to 
the operation of scaling, is by no means an objectionable practice. 
Not only does an acid, judiciously applied, cleanse the teeth thor- 
oughly, but it also destroys infusoria which are themselves, as we 
have seen, tartar ; and it serves as a stimulus to the deteriorated 
and generally spongy neighboring soft parts. Of acids which may 
be used for this purpose, none have advantage over the aromatic 
sulphuric, this being employed pure or diluted, according to the 
nature of the teeth to which it is applied, and the work proposed to 
be done with it. Acid is most conveniently used from the end of a 
pine stick, the detritus left by the scaler being softened and dissolved 
by it, and ulterior ill effects neutralized by frequent rinsing with 
ammoniated water. The objection that au acid will dissolve the lime 
salts of the teeth, as well as the offense against which it is directed, 
has as little weight as that a scaler will cut enamel, or that calomel 
will salivate, 






CHAPTER XXIII. 

DENUDATION. 

This affection, at once appreciated by referring to the drawings, 
is, without doubt, one of the most deforming conditions to which the 
dental organs are subject. It is sometimes seen attacking every 
individual tooth ; at others, confining its ravages to a very few. A 
very common seat of the affection is where the gum festoons. Here 
may be seen a sulcus or groove passing from tooth to tooth, involv- 
ing all those situated in the anterior part of the arch. Another 
form of the affection involves the cutting edges alone ; while in still 
other cases the depressions are situated promiscuously over every 
portion of the teeth. 

The disease, commencing as a slight gutter or break in the 
enamel, progresses with a varying degree of rapidity, sometimes 
Figs. 215 and 216. — Denudation. 





moving with such slow pace as scarcely to be observed from year to 
year; in other instances, and these, unfortunately, much the most 
frequent, making constant attention necessary to the preservation of 
the organs. Occasionally the process begins at a number of points, 
and these, enlarging, finally coalesce, to the destruction not unfre- 
quently of all the anterior enamel wall. 

Concerning the cause or causes inducing this condition, much 
diversity of opinion exists. The present conviction of the author is 
that the true explanation is just now, for the first time, enunciated 
in the electro-chemical experiments made by Mr. Kencely Bridgman 
(see Dental Caries), and that in this direction -will be found to lie 
not alone the cause, but the prophylaxis. As all that may be said on 
this subject is expressed in the experiments themselves, the careful 
attention of the reader is directed to them. True it would seem to 
be, however, that back of the immediately-acting cause must lie a 
predisposition : here would seem to be the result of impressions made 
on the enamel at the period of its formation, and which deficiency 

(505) 



506 ORAL DISEASES AND SURGERY, 

the nutritive functions have failed to correct. It might, indeed, very 
well be that such enamel is entirely deficient in vital resistance, and 
thus subject to be acted on as any inorganic structure, being by 
electrolytic action simply dissolved. To combat such a condition, 
electrolysis must be negated. If the assumptions from the experi- 
ments of Mr. Bridgman, here made, and which seem to the author 
so rational, be accepted, the treatment of denudation is the antag- 
onism of electro-chemical action ; this perhaps alone, as devitalized 
enamel might not be aided by vital defense. 

Treatment of denudation has heretofore been confined exclusively 
to combating by operative means the ravages inflicted, such means 
consisting in reaming out and filling with metal the cavities, as one 
after another may threaten from its extent and depth. 

Abrasion of the cutting face of the teeth from mechanical causes is 
a very common affection, and a very unfortunate one. The articula- 
tion of the two dentures has much to do with the production of such a 
condition ; indeed, everything, if we except an abnormal softness 
of enamel as found in certain teeth. Teeth that articulate scissor- 
fashion, the one set over or in front of the other, seldom suffer from 
this trouble. It is most markedly an affliction of direct articulatiou. 

Persons having jaws thus articulated find their teeth year by year 
wearing shorter; and were it not that, as this abrasion goes on, 
nature offsets the waste by internal repairs, throwing out layer after 
layer of secondary dentine, the dental pulps would be quickly enough 
exposed. 

The character of food used, while perhaps it would never yield 
this condition, yet, the predisposition in the articulation existing, 
without doubt assists in the destruction. Thus, it is remarked that 
sailors, eating constantly of hard bread, and chewers of tobacco, are 
most subject to abrasion. This is strictly true, however, only as it 
applies to such as have the peculiarity of articulation, and with such 
the progress of abrasion is commonly very rapid. 

A means of relief to this condition which, while fairly successful, 
is associated with more or less discomfort, consists in the adaptation 
to the posterior teeth of caps of metal. These caps take the strain 
of mastication, and thus protect the teeth. Another mode, but 
which is apt to excite inflammation, consists in cutting out cavities 
from the abrading faces of the teeth, and supplying the place of the 
removed dentine with plugs of gold. This latter plan has many 
advocates, and is highly commended by practitioners of experience 
and judgment. 



CHAPTER XXI Y. 



SALIVARY FISTULA. 



By a salivary fistule is meant a break in the continuity of structure, 
either of a salivary gland itself or its tube of outlet, through which 
break the secretion is poured over external parts rather than passing 
into the mouth to fulfill its recrementitial offices. 

The causes of salivary fistulae are various. In children, cancrum 
oris has frequently so sloughed away portions of the cheek as to 
produce the most intractable sinuses, necessitating, indeed, plastic 
operations for their cure. 

Wounds of lacerated character, and burns, are other causes of such 
fistulae. Abscesses, osseous and dental, venting through the cheek 
and involving in their course the Stenonian duct, are causes with 
which the author has several times met. Epithelial cancers eroding 
the cheek are conditions encountered. Salivation, once a most 
common cause, is fortunately now seldom met with. Surgical 
operations exposing the glands or ducts are to be enumerated as 
causes. 

A rare cause of salivary fistulae met with by the author on two 
different occasions, the diagnoses of which have been verified by 
removal of the organ, consists in an apparent subcutaneous ulcer- 
ation of several lobules of the gland, the secretion being thus in 
small quantity continuously discharged and forming hydrocele. In 
one of these instances — to be detailed — an adventitious sinus led the 
secretion from the sublingual gland to the supra-hyoid bursa, forming 
a cyst as large as the fist. 

The principle of the treatment of salivary fistule is found in re- 
storing by any capable means the original tube of passage. 

Fig. 21? exhibits a fistule upon the cheek, the break being into 
the duct of Steno, near its orifice. On the same diagram, situated 
just above the angle of the jaw, is shown a second. This represents 
the condition as connected with the gland proper. 

Fistulae are treated by cauterization and by operation. The first 
manner has its application particularly in exposures of the substance 

(507) 



508 



ORAL DISEASES AND SURGERY. 



of the glands, and perhaps in most of such instances invites to a 
trial which shall precede operative measures. 

Fio. 217. — Salivary Fistule — from Life. 




A mode of cauterization, which has the commendation of several 
successful cases reported, consists in pointing a stick of nitrate of 
silver, and forcing it through the track of the sinus down to the 
gland. When a sinus is straight, and the caustic may thus be made 
to reach the place of disease in the organ, the practice is to be highly 
commended. In the tortuous track, however, such a means may not 
apply ; the track may be closed, but, the surface of secretion being 
unobliterated, the accumulating secretion needs but a very short 
time to re-establish the track. Fistulas of irregular track connected 
with the glands are, with most hope of success, through this means 
treated by injection. Such injection may be saturated solutions, if 
deemed necessary, and may be either of the nitrate of silver, of 
chloride of zinc, or of iodine. 

Of the operative means resorted to for the cure of salivary fis- 
tulas quite a variety have been practiced. A common operation, and 
one most easily performed, applicable particularly to breaks in the 
continuity of the Stenonian duct, consists in taking a strand of well- 
waxed ligature silk, threaded at each end to straight or curved 
needles, as preferred. Seeking the bottom of the fistule, the first 
needle is thrust through the cheek into the vestibule, and brought 
out at the orifice of the mouth ; the second needle is now passed to 
the bottom of the fistule precisely as the first, and is also thrust 
through into the vestibule, but leaving some little tissue between its 



SALIVARY FISTULA. 509 

exit and the line of the first. The two ends being out of the mouth, 
a single knot is made, drawing it close up to the mucous surface of 
the cheek, strangulating the contained tissue. The strangulation, 
however, is not absolutely necessary, many surgeons, indeed, pre- 
ferring the knot loose, and to have the new passage resultant simply 
from the presence of the silk. With such a new passage, the origi- 
nal fistule will frequently tend to close. Particularly will this be 
found the case where the new passage has been so made as to afford 
easier exit for the fluid than the fistule. 

A second plan of operation is one devised by the late Professor 
Horner, of the University of Pennsylvania, and is that preferred 
and practiced by many surgeons. Fig. 3, Plate VI., exhibits this 
operation. Employing a punch, a simple incision is first made from 
the surface of the cheek down to the line and position of the duct: 
placing now against the mucous aspect of the cheek a wooden 
spatula, the punch is directed to the bottom of the superficial wound 
made by the knife, and then pushed through to the spatula, thus, as 
is seen, cutting out a section of the tissue, and affording a track to 
the discharge. The external incision is closed, and attempt made to 
secure immediate union. 

As a study in a class of cases oftentimes found quite defying, the 
following may be offered. 

The patient, a gentleman of excellent constitution and in easy 
circumstances, suffering from a carious wisdom-tooth, had sought 
relief in its extraction. The dentist, however, had the misfortune 
to break the tooth, and was unable to remove the fang. From the 
resulting irritation, conjoined with that residing in the broken and 
inflamed root, caries of the bone was induced ; this, in its turn, 
inflaming the cheek, an abscess formed ; this opened externally, 
involving in its passage the duct of Steno, thus producing fistule. 
The condition of the patient was as follows : the natural outlet of 
the gland continued patulous ; consequently, to the comfort of the 
case, much of the secretion found its way into the mouth. Through 
the artificial channel enough, however, escaped to keep the cheek 
constantly bathed with saliva and pus, the orifice being continuously 
covered with a large, but soft and pasty, imperfect scab. Of course, 
so long as the saliva discharged through this channel, it was im- 
possible for nature to close it. 

In this case, — which had been under the treatment of different 
persons for over two years, — three weeks, lacking three days, were 
required for the cure. First, examination was directed to the eondi- 



510 ORAL DISEASES AND SURGERY. 

tion of the underlying parts. The caries of the bone being found 
cured, the depth and course of the fistule were discovered by the use 
of the ordinary silver probe. This, for three days, was enlarged by 
the introduction, each day, of a twisted tent of cotton. At the end 
of this period a slender, straight-bladed bistoury was passed directly 
through the cheek into the mouth. An eyed probe was next 
threaded with a cotton tent, large and thick at the part which was 
to occupy the inner half of the thickness of the cheek, delicate and 
as threadlike as it could be made where it was to be lodged in the 
external track of the fistule. By the aid of the probe this tent was 
carried through the cheek, and was then fixed in position by a little 
slip of adhesive plaster, attaching it to the cheek. This tent, being 
kept clean and disinfected by daily syringing, was retained in posi- 
tion one week, the swelling of the inner bulky portion having by this 
time resulted in the formation of quite a channel, with a correspond- 
ing diminution in the diameter of the fistule. At this stage the 
cotton was replaced with a wire seton, made by taking the most 
delicate of ligature iron wire, and doubling it upon itself a number of 
times to half the thickness of the cheek, a single strand continuing 
the length designed to occupy the line of the fistule. To replace the 
one with the other it was only necessary to attach them by an in- 
termediate strand of silk: as one was withdrawn, the other occu- 
pied its place. This wire seton was thus inserted, and was held 
in place by perforated shots clamped on each extremity. In one 
week the external or original fistule had closed so as to hug the 
wire, the discharge being entirely into the mouth. The seton was 
now withdrawn entirely, and on the next day complete closure was 
found to have resulted. The case was thus dismissed cured, and 
has remained so. 

A fistule of the parotid gland proper, failing to close upon cauteri- 
zation, may be treated precisely as the case just detailed. In place, 
however, of the pyramidal coil, a rope of wire is to be used, three 
or more strands being twisted together; the track leading to the 
mouth is to be the shortest that may be selected. 

Fig. 218 represents a case and operation having the following 
history: it will be seen, however, to come as properly under the head 
of ranula as of fistula. The drawing is from a photograph taken at 
the time of the operation. 

First it was noticed by the patient that the parts beneath the 
chin began to soften and grow broad, freedom of motion was lost 
in the jaw, and a slight sense of difficulty was experienced in 



SALIVARY FISTULA. 511 

speech, as the result of stiffness about the tongue, the floor of the 
mouth being quite indurated. In the course of four months, a tumor, 

Fig. 218. 




evidently cystic, and fully the size of an ordinary orange, occupied 
the front of the neck, but happily concealed by the long and heavy 
beard of the patient. 

Presenting himself for a cure, a diagnosis as to the general nature 
of the tumor was secured through the aid of an exploring-needle ; 
this valuable instrument demonstrating not only that the tumefac- 
tion was cystiform, but affording an idea of the contents. 

Treating the tumor as a cyst of an immediate signification, as a 
hydrocele, a bistoury making a reasonable incision was passed into 
the most pendent part; the contents, a mass of lymph-like fluid, 
filling a large goblet, issued as a continuous rope ; in color and con- 
sistence it might have been likened to thin calves-foot jelly. The 
cavity having been thoroughly washed with warm alum-water, 
compresses were carefully adjusted to the parts and sustained by 
the author's strip bandage. In two weeks, and without any 
trouble, the parts had united, and the cyst seemed permanently 
obliterated. 

One month later the patient again presented himself. The tumor 
was re-forming : the cyst apparently had not been obliterated ; 
already it was the size of a walnut. A few days later a second 
operation was performed precisely as in the first instance ; the con- 
tents of the cyst differed, however, at least in color, having the same 
colloid consistence, but being blood-red. After the incision, and after 



512 ORAL DISEASES AND SURGERY. 

evacuating the cavity, determined on obliterating the cyst, I syringed 
it with the officinal tincture of iodine, undiluted, stuffing the cyst 
afterward loosely with cotton. I this time succeeded in producing 
a perfect cure ; but the swelling, associated with the inflammation 
produced by the injection, was so great that it was only with the aid 
of leeches, and cathartic and diaphoretic medicines, combined with 
the closest attention, extending over four days, that I succeeded in 
preserving the man's life : for two whole days the patient was uuable 
to swallow even teaspoonful measures of water, and breathed with 
the greatest difficulty. 

What was this tumor ? Evidently a hydro-hematocele, the start- 
ing-point of the lesion being, I think, in a sublingual gland. It 
might be suggested that, had it belonged to this gland, the swelling 
would have exhibited itself more in the mouth. My reason for 
inferring that it was so associated lay in the fact that a blunt probe 
passed into the cavity could readily be felt in the position of the 
left of these bodies, in the mouth. 

3fC 3ft Tfi. *£ 3JC 3JC "^C 

The preceding history of this case is one of the illustrations 
offered in the chapter on Ranula, published in " Diseases and Sur- 
gery of the Mouth, Jaws, and Associate Parts :" it was written 
four months after every evidence existed as to the completeness of 
a cure. 

As a coincidence, it occurred that, on the very day on which the 
perfected proofs of the chapter were put into my hands (the form 
being struck off), this patient again presented himself, the neck 
exhibiting every evidence of a return of the tumor. 

I now determined on and practiced an operation which exposes 
the case in its most instructive light. 

As illustrated in the diagram, a crucial incision was made, ex- 
posing, in the retraction of the flaps, the common deep fascia of the 
neck, which fascia constituted the floor of the cyst, and was, in 
appearance and consistence, apparently natural. 

Passing into a sinus in this deep fascia, and emerging from the 
mouth, the reader observes the probe. The orifice of this sinus 
was very small, and was only seen after the parts had been thor- 
oughly cleansed ; the track was exceedingly tortuous, and was not 
passed until after several attempts, and only at last by the experi- 
mental bending of the probe. 

On reaching the floor of the mouth, it was evident enough that 
the instrument struck the sublingual gland, as without effort this 



SALIVARY FJSTUL^E. 513 

body could be thrust upward from its bed. To thus elevate and 
dissect out the organ, which was done, was a matter of no difficulty. 
To complete the operation, the walls of the cyst were slightly 
cauterized with the solid stick of nitrate of silver, and the flaps laid 
in place, and secured with the necessary stitches of interrupted su- 
ture ; adhesion was secured by compresses continued over a month. 
Examination of the resected gland discovered upon its under 
surface a break in its continuity, evidently pathological and of long 
standing; thus was demonstrated the ranulous character of the 
tumor. Little by little the salivary secretion had worked this 
passage downward, securing, by its slow progress, an adventitious 
tissue, or walled sinus. 

Looked at from the cervical base, one would naturally have 
viewed the sinus as being made by a prolongation of the fascia, so 
precisely did it look as though a tubular cul-de-sac had elongated 
itself until it had met and associated itself with the base of the 
gland. 

The question of the location of this tumor is not without a special 
interest. 

Does it prove the existence of a supra-hyoid bursa, described by 
some anatomists and searched for in vain by many others ? If such 
bursa had not, in this particular case at least, an existence, how 
shall we as naturally explain the presence of the perfect cyst which 
formed the tumor ? 

A second point of interest lies in the fact of the reaching of the 
gland described in the first diagnosis made months before. This, it 
would seem, could only have been the result of a rare accident, 
which on that occasion directed the probe into the sinus, and gave 
to the parts that favorable position which made the passage a direct 
one. 

This case, viewed from the standpoint of fistula, is one of great 
interest and instructiveness : had the tumor been allowed to en- 
large and attenuate the walls, and thus to rupture, it is evident that 
the case would have been. one of salivary fistula proper. 
As another illustration, the following case may be given: 

Mr. , an old gentleman, had upon his right cheek an ulcer 

the size of a dime-piece. This sore, subjected to a great variety of 
treatment at different hands, obstinately refused to heal, yet did not 
grow worse. Decided to be epithelioma, it was finally let alone, 
mild dressing being employed simply as a protection. 

Carefully absorbing from the face of this ulcer the moisture and 

33 



514 ORAL DISEASES AND SURGERY. 

pus with which it was always covered, having at the time the eve 
upon the sore, it could be noticed that almost immediately the part 
became remoistened by a watery film. This leading to the inference 
of an association with the salivary duct, search was made, through 
the agency of a magnifying-glass, for any expression of communi- 
cation which might exist, — a sinus of most minute calibre being 
discovered. Here at once was the signification of the ulcer. A cure 
was quickly effected by the employment of the thread seton. 

Still another character of cases is found, where, from the existence 
of a minute break in the continuity of the Stenonian duct, the nat- 
ural outlet being normal, a cystic form of tumor of most indolent 
character is found in the substance of the cheek. I have met with 
several of these cases, and at first was entirely deceived, making 
matters worse by opening them. The diagnosis is found in the ex- 
ercise of a patient manipulation, which may empty the cyst, forcing 
the saliva back into the duct. Compression, with stimulation, is the 
principle of cure. If opened by mistake, they are to be treated like 
any other form of the condition. 

A condition somewhat the reverse of the last, being one of most 
simple signification and diagnosis, is occasionally to be met with, 
where, from some active cause of obstruction about the tube of 
Steno, a tumor of rapid formation is found along the line of the duct. 
This is simply a species of ranula, but, if untreated, may form a 
fistula by ulcerating externally. To combat successfully such a con- 
dition, it is desirable to enlarge or render patulous the natural outlet 
by insinuating into the canal a threaded probe. This, being carried 
into the tumor, is incised upon. Through an opening thus made, 
the probe, followed by its thread, is to be withdrawn ; the interme- 
diate line — being that of the stricture — is now included in a loop, 
which is to be left to take care of itself. 

Having treated many cases of salivary fistula, anomalies of vari- 
ous significance and interest have no doubt been met with by the 
author, which do not at present recall themselves. The principle of 
treatment for every form and variety may only, however, be a com- 
mon one. 






-~r*.. 



K 



«n^4 



Plate VI 











/ 



;•-. 



> 







. 



PLATE VI. 

A VIEW OF THE ANATOMY OF THE SIDE OF THE FACE, AND OF SOME 
OF THE OPERATIONS PRACTICED ON IT. 

Fig. 1. — A side view of the Anatomy of the Face after the removal of the 
integuments. 1. The shape and position of the parotid gland. 2. 
The duct of Steno. 3. The sublingual gland. 4. The facial artery, 
at the point where it passes on to the face. 5. The facial vein. 6. 
The sterno-cleido-mastoid muscle. 7. The external jugular vein. 
8. The zygomatic muscle. 9. Branches of the portio dura nerve 
emerging from the upper edge of the parotid ; other branches are 
seen on the face. — After Bernard and Huette. 

Fig. 2. — The same Section after the removal of the Parotid Gland. 1. The 
portio dura uerve at its exit from the stylo-mastoid foramen. 2. 
The duct of Steno divided transversely. 3. The external carotid 
artery when freed from the parotid. 4. The temporal artery. 5. 
The facial artery after removal of the sublingual gland. 6. The 
sterno-cleido muscle. 7. Main trunk of the external jugular 
vein. — After Bernard and Haette. 

Fig. 3. — A three-quarter view of Horner's operation for the cure of Salivary 
Fistula. A wooden spatula supports the inside of the cheek; a 
slight longitudinal incision is made at the external fistulous orifice, 
and the hand of the surgeon is seen pressing the punch against the 
spatula so as to cut out a piece through the cheek. The external 
incision, being closed by a point of a suture, heals usually by the 
first intention, leaving the orifice, made by the punch, open in the 
mouth. — Drawn fromNature. 

Fig. 4. — A view of the operation of Resection of the Upper Jaw, as practiced 
by the incision of Warren. 1, 2, 3. The flaps everted, and turned 
over the nose and eye so as to expose the bone. The left hand of 
the surgeon is holding, 4, the bone at the moment of disarticu- 
lation by the knife, 5, which is working at the pterygo-maxillary 
fissure. Yelpeau's operation is nearly the same as that of War- 
ren. — After Bernard and Huette. 

Fig. 5. — Represents the completion of the operation, the union of the wound 
by the twisted suture, and the line of the cicatrix, which extends 
from the malar bone to the mouth near, but not at, the angle. — 
After Bernard and Huette. 

Fig. 6. — A view of the termination of Gensoul's operation, showing the lines 
of his incision. 1, 2. The first incision across the tumor. 3, 4. 
The second incision. 1, 5. The third incision, forming flaps, which 
are to be turned up and down upon the face. The sutures are seen 
as placed at the termination of the operation. — After Gensoul. 

Note. — Figs. 4, 5, and 6 refer to operations considered in another connection. 

(515) 



CHAPTER XXV. 



THE TONSIL GLANDS. 



Fig. 219. 



The tonsil glands, situated on either side of the fauces, between 
the half arches, are readily exposed by depressing the tongue through 
the instrumentality of any convenient means. An instrument made 
especially for the purpose, called a " depressor," will be found very 
well adapted.* 

The tonsils, glandular organs, expressed 
by Yirchow as being the analogue of the 
lymphatic glands, are made up of many 
lobules, congeries of mucous follicles, with 
intervening sulci lined by involutions of the 
common mucous membrane. Inflammation, 
simple or acute, and chronic or morbid, is the 
disease of these glands. With the first are 
associated the various features of vascular 
change, passing from the most transient of 
congestions to the most threatening of ab- 

The Tonsil Glands. SCeSSeS. 

Simple tonsillitis — angina tonsillaris — amygdalitis — is an inflam- 
mation of the substance of the gland. Looking into the mouth, the 
bodies, one or both, are discovered unduly colored and swollen. If 
the inflammation is of any severity in its grade, the patient experi- 
ences pain and difficulty in swallowing, with a sense of dryness, 
heat, and fever in the fauces ; and these discomforts, influenced 
by the character of the attack, may progress until it becomes im- 
possible to swallow, and in many cases exceedingly difficult to 
breathe. 

As a gargle, found most reliable in such cases, — or rather as an 




* It is a singular fact that depression of the tongue is secured by simply 
laying the depressor upon it. "When force is employed, the organ, in many 
cases, spasmodically resists, crowding against the roof of the mouth. 
(516) 



THE TONSIL GLANDS. 517 

application to let fall and hold in contact with the parts, for the act 
of gargling may be impossible, — the following may be employed : 

R. — Plumbi acetatis, Jj ; 
Tincturae opii, 3j 5 
Aquae, ^xij. M. 

A second medicament, highly esteemed by many, consists in a 
combination of tannin and glycerine, the application being made to 
the parts with a brush. 

In the frequent cases in which the congestion is associated with 
passivity, resolution will be found oftentimes quickly effected by a 
gargle compounded as follows : 

R. — Soda3 biboratis, 3iij ; 
Potassaa chloratis, 3j 5 
Tincturae capsici, 3ij; 
Tincturae m vrrhae, Jj ; 
Aquas, §viij. M. 

Another practice, which the author has found happily applicable 
to these latter conditions, consists in first brushing the parts with a 
solution of nitrate of silver, four grains to the ounce of water, and 
afterward using a compound iodine and carbolic acid gargle. 

R. — Tincturae iodinii composite, gtt. xl ; 
Acidi carbolici fluidi, gtt. vj ; 
Glycerin 83, I] ; 
Aquae, ^vij. M. 

Tincture of belladonna has lately received much commendation 
as a remedy in acute tonsillitis, — being administered in from two- to 
fifteen-drop doses, repeated every two hours until the patient is re- 
lieved, or until contra-indicated, either as great dryness in the throat 
is induced, or as the pupil exhibits relaxation. Local applications 
are also highly commended, the medicine, it being affirmed, having 
the same action whether applied locally or given internally, — that is, 
diminishing the calibre of the capillaries by its action on the vaso- 
motor system of nerves. 

Sympathetic inflammation of the tonsil glands is not infrequent. 
Among the most common of such relations, and where a treatment 
must of necessity consider the influencing lesion, are croup, scarlet 
fever, measles, diphtheria, typhoid fever, and syphilis. 



518 ORAL DISEASES AND SURGERY. 

Glancing at the view, which exhibits the glands in a state of par- 
tial enlargement, it is plainly enough seen that the isthmus would 
be closed in proportion to such enlargement : hence the difficulty 
experienced in deglutition and respiration. Tonsillitis ends either 
in resolution or suppuration. 

When the inflammation is met with in its incipiency, attempts are 
at once to be made to resolve it by the use of antiphlogistic remedies. 
Free scarification has occasionally been resorted to with the best 
results. Leeches externally applied between the angle of the jaw 
and the sterno-cleido-mastoid muscle, — to be employed only, how- 
ever, in the vigorous and plethoric, — and blisters, directed to the 
nape of the neck, will be found of the greatest service. Hot foot- 
baths, continued until the veins of the legs are engorged, or until 
diaphoresis results, or the patient grows faint, constitute a most 
satisfactory and reliable means of relief. If the inflammation should 
have advanced to a point in which the system at large sympathizes, 
as exhibited by the presence of fever, hope is still to be entertained 
of recovery by resolution. In these cases I have found it good 
practice to place the patient over a basin of steaming water, and, 
with the form enveloped up to the very mouth in blankets, secure 
diaphoresis by a plentiful exhibition of the spiritus Mindereri — a 
tablespoonful every ten minutes until the desired result is produced. 
This, if the patient is robust, may be succeeded by a saline cathartic. 
As a local treatment, it will be found very agreeable to order a 
lemonade, made by crushing ice in a towel or napkin; the small 
particles of the ice thus acidulated may be taken little by little into 
the mouth, and allowed gradually to dissolve. Another application 
consists in a gargle of flaxseed tea, in which is dissolved the chlorate 
of potash. Tartar emetic, or the tincture of digitalis, or of veratrum 
viride, administered internally, is of much use in controlling the 
circulation. A very useful combination, where the circulation runs 
high and the system is irritable, is as follows : 

R. — Liquoris potassse citratis, giij ; 
Spiritus setheris nitrosi, ^ss ; 
Tincturae veratri viridis, gtt. xxv. M. 
Sig. — From 5j to ^ss, according to age and requirements. 

In most cases of tonsillitis where the inflammation is excessive, 
the uvula will be found to participate ; swelling occurring, through 
serous effusions, not unfrequently to such an extent as to threaten 



THE TONSIL GLANDS. 519 

immediate suffocation, the organ dropping into the chink of the 
glottis. In these cases it may be proper first to try an application 
of the tincture of iodine ; but should this fail, — which, in the ex- 
perience of the author, will be found most likely, — immediate resort 
is to be had to section of the mucous sac holding the effusion ; such 
a cut will quickly cause the swelling to disappear. Circumstances 
sometimes arise where an opening into the larynx or the trachea 
affords the only chance to a patient for his life. 

Where, in defiance of all treatment, a tonsillitis, whatever its sig- 
nification, determines toward suppuration, the best that can be done 
is to hasten the process as rapidly as possible, providing, always, 
that the attendant swelling is not formidably extensive. In these 
latter cases nothing better can be done than to make premature in- 
cisions. Where the swelling is not extensive or threatening, gargles 
of flaxseed tea will be found both soothing and encouraging to the 
formation of pus, and may be used with all freedom. 

Where pus has formed in a gland, it is a proper practice to void 
it with the knife as soon as recognized. This may be done with 
most safety, perhaps, by using an ordinary tenotome, or, as has been 
recommended, by a gum lancet. 

In inflammation of the tonsil glands occurring in the weak and 
depressed, the abstraction of blood is never perhaps advisable ; too 
much care cannot be exercised in this direction. 

Hypertrophy, or chronic enlargement, of the tonsils, is a condition 
most common to scrofulous children, and pertains, consequently, to 
early life, being, indeed, very rare after puberty, and never perhaps 
seen in old age : of the various patients upon whom I have operated 
for the relief of this affection, there have been but four over thirteen 
years of age. The enlarged or hypertrophied tonsil differs very much 
in consistence and character in different cases, being in one patient 
indurated and smooth, in another spongy and lobulated. In color an 
equal variety is presented, varying in appearance from the scarlet of 
an arterial injection to the dull blue of a passive venous stagnation. 
One of the inconveniences associated with enlarged tonsils is the 
effort required in respiration, particularly during sleep, such effort 
in many cases being really painful to witness. Another is the 
interference with hearing, pressure upon the Eustachian tube fre- 
quently occluding this passage, particularly when the patient takes 
cold. Speech is interfered with : to sing softly and finely with the 
tonsils enlarged is impossible. 




520 ORAL DISEASES AND SURGERY. 

Tonsillar hypertrophy being a systemic expression rather than a 
strictly local disease, very little true benefit has been derived from 
v 220 ^ e em pl°y men t °f tne great variety of direct 

remedies which from time to time have been 
recommended. A patient so afflicted is to be 
treated from the constitutional standpoint ; and 
to this end nothing in my experience has been 
more conducive to good than cold salt-water 
bathing: indeed, I am of opinion that, as a 
rule, more attention will be found required to 

Hypertrophied Tonsil. * 

the direction of diet, clothing, exercise, and 
general mode of life than to the administration of medicine. Where, 
however, medication seems demanded, it is to be directed to the 
correction of any observable constitutional defect or irregularity. 
Iodine and its preparations are not always, by any means, indi- 
cated ; and not unfrequently, from their exhibition, by a further 
debasement of the vital powers, much more harm than good has 
resulted. It does not seem possible to lay down rules that shall 
apply to the constitutional treatment of such cases, except so far as 
to suggest attention to all the functions and the general tonic medi- 
cation mostly, if not always, demanded. 

Among medicines professed to be possessed of specific significa- 
tion, used for enlarged tonsils, sulphate of potassa holds the most 
prominent position. This preparation, given in doses of from five 
to fifteen grains, continued for a month or six weeks, will, without 
doubt, in many cases, cause the hypertrophy to disappear. It is 
usual to combine with it rhubarb and some of the aromatics, suffi- 
cient to insure mere laxity of the bowels. 

Where enlargement of the tonsils associates with the rheumatic or 
gouty diathesis, colchicum has been highly commended : to be taken 
internally, and applied externally as a liniment in combination with 
the linimentum saponis. The use of colchicum in such direction was 
originally introduced into English practice by a Mr. Harvey, he being 
led to his conclusions by observing the relationship of the contents 
of the tonsillar follicles with the concretions found in the joints of 
the rheumatic and gouty.* 

* Foul breath, so frequently associated with the soft variety of tonsillar 
hypertrophy, arises from the degeneration of the sebaceous secretion retained 
within the crypts, and from the inspissated mucus enveloping the glands. The 
phenate of soda, chlorine-water, or a solution of the permanganate of potash, 
either of these being combined with the compound tincture of capsicum, will 
be found satisfactory for the purpose of temporarj 7 relief. 



THE TONSIL GLANDS. 521 

Another remedy, having the commendation which associates with 
frequent successful response, and particularly applicable where the 
condition is coincident with scarlatina, is found in the acetate of 
zinc: it is prescribed from 9j to 3j in from %v] to ^viij of water 
and glycerine, given in tablespoonful doses every four hours, or in 
the acute, severe cases, oftener. It is well to retain it for a moment 
in contact with the tonsils before swallowing. 

The local treatment of hypertrophied tonsil glands resolves itself 
into the threefold direction of the use of alteratives, destruction 
by cauterization, and amputation. Of the first of these means, the 
iodide of zinc holds, perhaps, the most prominent position. It is 
used in solution of from ten to thirty grains, being applied with 
a brush two or three times in the twenty-four hours ; or, as the 
treatment advances, it may be applied pure, as it deliquesces when 
exposed to the atmosphere. 

Pressure by the finger, frequently repeated, punctures with the 
point of a bistoury, gargles of capsicum, — means of such character 
may be tried, as judgment shall make preference for one or the other. 
It is to be regretted, however, that the promise by such mode of 
treatment is not the most satisfactory; and it is always to be borne 
in mind that if such agents are found to do good even by controlling 
the enlargement, it may be prudent to rest satisfied, as advancing 
age will generally be found to afford correction to the trouble. 

The second mode of treatment — that by cauterant destruction — 
may be said to have been made most practical by A. Ruppaner, 
M.D., of New York. A practice introduced by this gentleman, and 
whose successes have been verified in quite a number of cases by 
the author in his own practice, consists in the use of the London 
paste recommended by Dr. Morrell Mackenzie. The following are 
the directions for the preparation and use of this paste : 

" A quantity of equal parts of finely-pulverized and well-mixed 
caustic soda and unslacked lime is kept on hand. When an appli- 
cation is to be made to the tonsils, a little of the powder is put into 
a small porcelain cup ; a few drops of absolute alcohol, which is 
kept near at hand, are added ; the two are carefully mixed with a 
glass rod, when the paste is ready for use. Care must, however, be 
taken that it be of the proper consistency. If too thin, it is apt to 
find its way to parts which ought not to be touched ; if too thick 
or lumpy, the paste will not readily stick, and little pieces might 
be swallowed. To apply the paste, a glass rod of sufficient length 
ought to be used. One end of it, which must be smooth and slightly 



522 ORAL DISEASES AND SURGERY. 

funnel-shape, is dipped into the paste, and a greater or lesser portion 
of the surface/touched, as occasion may require. 

" To apply the paste, the patient should be placed in the position 
for laryngoscopy. The tongue is then to be depressed with the 
spatula, and the paste applied to the enlarged surface for two or 
three seconds. The action of the escharotic upon the tonsil is rapid. 
The mucous membrane almost instantly assumes a deep flesh color, 
and presently a dark, blackish spot is seen streaked with blood. 
The following day the tonsil is covered with a whitish -yellow 
eschar. 

" The inconsiderable amount of suffering produced by this applica- 
tion is noticeable. Children hardly pay any attention to the pain, 
or make light of it. At the longest, the discomfort lasts only about 
two or three minutes. Subsequent applications are accompanied 
with less, if any pain at all. 

" The operation is again to be repeated in two or three days. The 
number of applications will depend upon the nature of the case. 

" Our author reports one hundred and twenty-three cases treated 
in this manner: the minimum number of applications of the paste, 
in any case, was six; the maximum, fourteen." — Modern Therapeu- 
tics. 

The good results obtained from the use of this paste are not 
exaggerated by Dr. Ruppaner. Still, the experience of the author 
makes him unwilling to agree that such mode of cure should be 
found to dispense entirely with the use of the knife. Excision of the 
tonsils is an operation of almost instantaneous performance, and the 
results may be said to be always complete. The practitioner who is 
inexperienced in the use of the knife may, however, place full con- 
fidence in the use of the London paste. 

Dr. Rumbold, of St. Louis, Missouri {Medical Archives), claims 
to have treated successfully a number of cases of enlarged tonsils 
by injecting the glands, by means of a hypodermic syringe, with a 
solution of iodine (R. — Iodinii, gr. ij ; potassii iodicli, 9ij ; aquae, *j). 
Generally a slight inflammation followed the injection, but it soon 
subsided. From twelve to seventeen injections — ordinarily two a 
week — were sufficient to reduce the gland to its normal condition. 
The advantage claimed for this mode of treatment was its saving 
the substance and function of the gland. 

Amputation of the enlarged tonsil is to be effected either with 
the bistoury or the tonsillotome, the latter instrument being that 
which most recommends itself. Fig. 221 exhibits such an instrument. 






THE TONSIL GLANDS. 



523 



Fig. 221. 



The principle of the tonsillotome is that of the guillotine. Of these 
instruments there are a variety, a single mode of operation being 
common, however, to all of them. The con- 
struction embraces, first, a fenestra, to encir- 
cle the gland ; second, a slide-pin, to catch 
and hold the organ ; and third, a triangular 
blade, for the excision. Of these instruments, 
some cut by having the knife drawn forward. 
This is the manner of that known as the 
Fahnestock blade. Others, as the Physick, have 
the motion forward. An improvement lately 
made on the Physick instrument, by Mr. 
Kolbe, consists in an addition of automatic 
fingers and ringed lever-handles. To use this 
instrument it is only necessary to carry the 
fenestra over the gland, when, by the simple 
closure of the handles, the fingers grasp and 
pull the gland under the blade, which, in a 
synchronous movement, cuts it off. 

To apply the tonsillotome to the gland of 
the right side, the surgeon finds his greatest 
convenience in leaning over the thrown-back 
head of the patient. In using it for the left 
side, there is no better manner than to rest in 
front of the patient upon the right knee, thus 
placing the fenestra with facility, and, if the 
Kolbe instrument is used, holding it, while the 

handles are manipulated by an assistant. In using any of the slide- 
pin instruments, both pin and blade are best worked by the assistant, 
the surgeon fixing and retaining the fenestra exactly where it is 
desired that the section shall be made. 

In using the ordinary tonsillotome, occasion is not unfrequently 
found for the employment of means which shall allow of the gland 
being enveloped in the fenestra. When such difficulty is met, it 
complicates the operation to some extent, yet is easily to be over- 
come through the use of a vulsellum, the gland by this means being 
caught and dragged within the ring. 

The use of the bistoury as a means for the amputation of a tonsil 
gland is only to be indorsed when in most experienced and skillful 
hands ; results of the gravest nature might very readily arise 
through some unexpected and unanticipated movement on the part 




Tonsillotome — Physick. 



524 ORAL DISEASES AND SURGERY. 

of the patient, — a risk entirely avoided in the use of the first instru- 
ment. 

In operations upon young- children with the tonsillotome, it will 
be found best to employ ether, as otherwise the restlessness may 
interfere with the proper introduction of the instrument. After the 
excision of one tonsil the child should have its head immediately 
thrown forward, that the blood may not pass into the throat. As 
soon as hemorrhage has stopped, the ether may be readministered, 
and the section repeated upon the opposite side. 

Questions, however, will arise as to the advisability of the double 
operation at the same sitting, — questions of shock, of hemorrhage, 
of inflammatory sequela?, of idiosyncrasy. The experience of the 
author favors most decidedly two operations, the first to be in every 
respect recovered from before the second is attempted, — not, how- 
ever, that it is meant to imply that such care and caution are always 
necessary, or that indeed the single operation is his own constant 
practice : it is suggested as that attended with least risk. 

Many surgeons, immediately after this operation, and in many 
instances before it, administer, in anticipation of inflammatory 
trouble, a full dose of sulphate of magnesia. It is also thought 
well by many to protect the incised parts against the irritating 
influence of atmospheric changes by a confinement of several days 
in an even temperature. It may be accepted, however, that, if the 
weather be moderately mild, it will be found sufficient to keep 
the parts lubricated by a coating of gum acacia, secured by simply 
holding the pearls in the mouth until they dissolve. 

Hemorrhage, of any marked character, after the operation, is not 
common ; instances occur, however, where the tonsillar artery must 
be compressed, twisted, or tied; but, as a rule, there is no trouble 
from this source which a simple gargle of alum-water will not be 
quite sufficient to overcome. 

Of other surgical conditions associated with the amygdalae, ulcera- 
tion is, without doubt, the most common. Of the non-specific 
ulcers, all will be recognized to have the expression as described 
under the head of "the Aphthas" (which see). Specific ulcers are of 
two kinds, the venereal and the cancerous. A diagnosis of the former 
is readily to be made from the expressions found associated in other 
parts of the mouth.* The cancerous ulcer, being of the epithelial 



" The syphilitic affections of the tonsils are difficult todiagn 



ose, since even 



THE TONSIL GLANDS. 525 

variety, is to be recognized in the papilliform character of the gran- 
ulation, with which its surface is always found studded. The 
treatment of the first is to be that directed to the cure of the in- 
fluencing disease. (See Ulcers.) That of the second may only be 
founded on the most careful weighing of the circumstances of each 
case. Should such disease be recognized in its true character, when 
very circumscribed and non-infiltrated, it is justifiable to extirpate 
the gland. If not appreciated until the neighboring mucous mem- 
brane manifests its sympathy, an operation would be worse than 
useless. It has happened to the author to be consulted in several 
cases of epithelioma of the tonsil glands, but he has never seen one 
which warranted operation. 

Constitutional cancer, as a primary exhibition, is described as 
being seen in this gland. The author has never met with it except 
by implication. 

Complete extirpation of the gland, when indicated for a cancerous 
manifestation, would be best practiced by external incision. An 
operation so performed is recorded by Dr. Cheever, of Boston. In 
this case two incisions were made : one commencing within the angle 
of the jaw, and directed downward on a line parallel with the sterno- 
cleido-mastoideus ; the second forward, along the base of the jaw. 
The dissection in this case revealed, first, an enlarged lymphatic 
gland, which was removed ; second, the digastric, stylo-hyoid and 
st} r lo-glossus muscles, these being cut and pushed aside ; and third, the 
superior pharyngeal constrictor, the fibres of which were disparted, 
thus allowing the finger to reach and retract the gland. Twelve 
ligatures controlled the hemorrhage of the operation, and the patient 

tions, follicular abscesses, and cicatrices may frequently affect these organs 
and yet remain unnoticed. The crypts of the tonsils sometimes form exten- 
sive fistulous passages, thus constituting a persistent cause of altered secretion 
and of increased sensibility. If the hypertrophied tonsils are not removed, 
the surgeon should at least slit up these fistulous canals or cauterize them to 
a sufficient depth. Of the ordinary caustics, Prof. Sigmund prefers to nitrate 
of silver or bichloride of mercury the Vienna paste, immediately after the 
application of which the cauterized spot is to be washed with vinegar and 
water. Concentrated tincture of iodine may also be applied to ulcers with 
good results. Tannin is applied principally as a wash after the use of caus- 
tics, or as a retaining agent after brushing over the parts with tincture of 
iodine. All these applications, however, may be spared if the surgeon at 
once removes the hypertrophied tonsils, the most certain means of alle- 
viating and cutting short the course of syphilis in these organs." — Schmidt's 
JahrbucJier . 



526 ORAL DISEASES AND SURGEBY. 

is reported as having completely recovered in a month. Extirpation 
of the gland from within the mouth has been successfully accom- 
plished both by European and American surgeons. In a gland well 
solidified by the scirrhous expression, and possessed of a well-defined 
base, a catgut or wire ecraseur is to be used with great satisfaction. 

Cystic Disease. — The formation of a cyst or cysts within the 
gland is of rare occurrence. In his own immediate practice, the 
author has as yet never seen a case. Virchow, in his volume on 
Tumors, mentions them, however, as being of not infrequent oc- 
currence. The signification of such a cyst would most likely be 
found in occlusion of an orifice of outlet, while the treatment de- 
manded would be of such simple nature as applies to abscess or 
ranula. Should a cyst prove of malignant character, little harm 
would result from mistaking it for and treating it as one of simple 
form. The diagnosis of a cystic tonsil would necessarily result on 
touching such a cyst. 

Abscess. — Abscess of strumous signification is frequently to be 
met with in these glands. These abscesses belong truly to the 
cold or chronic variety, being oftentimes two or three months in 
maturing, seldom attended with pain, and imparting to the over- 
lying structure a dull white appearance, very characteristic. Such 
abscesses are to be treated from the constitutional as well as from 
a local standpoint. As a gargle, to be used several times a day, 
no medicament seems to equal the compound tincture of capsicum, 
3ij to ^viij of water being employed. Internally, cod-liver oil, 
combined with a chalybeate, will be found of the greatest service, 
and may be prescribed with great freedom. 

Occasions will be found to present, where, in acute tonsillar dis- 
ease, the surgeon, called in an emergency, is compelled quickly to 
decide on means which involve life or death. For such emergencies 
a judicious practitioner fully prepares himself. 

When convinced that a patient may not otherwise be relieved, and 
suffocation is imminent, the surgeon may, without hesitation, thrust 
a bistoury or scalpel directly through the crico-thyroid membrane. 
This operation, if no middle thyroid artery run over the membrane, 
is one of most simple character ; and if the parts be then separated, 
and kept so, either by the introduction of a tube, or by hooks of wire, 
which may pass around the neck, the patient will experience the 
greatest relief. When the artery crosses the membrane, and has 






THE TONSIL GLANDS. 



527 



thus been cut, the blood is to be prevented from entering the lungs 
by leaning the person forward, the face downward; the vessel is 



Fig. 222. — View of the Air-Tubes, 
a. b. 



0f!M'i'' : .h\0) 




A. Larynx, trachea, and bronchial tubes, viewed in front. 1, hyoid bone ; 2, thyro-hyoid 
membrane; 3, thyroid cartilage; 4, crico-thyroid membrane; 5, cricoid cartilage; 6, 
trachea; 7, 8, two cartilaginous rings; 9, membrane which separates them ; 10, right 
bronchus and its divisions ; 11, left bronchus. 

B. Larynx, trachea, and commencement of bronchial tubes, viewed from behind. 1, 
upper opening of larynx ; 2, 3, lateral grooves of larynx ; 4, fibrous membrane of trachea, 
interspersed with small glands, beneath which are seen 5, muscular fibres ; beneath this 
last are 6, 7, small fibrous bands; 8, mucous membrane seen between them. 



then to be secured in the most convenient manner, with ligature, if 
possible. 

Tracheotomy, an operation sometimes in such connection found 
compulsory, while seemingly complex, is yet not difficult of accom- 
plishment: at least the author has found himself able to perform it 
upon the living subject without assistance. Having the patient 
upon his back, with the neck extended, an incision is to be made 
directly in the middle line of the neck : this incision, under the cir- 



528 ORAL DISEASES AND SURGERY. 

cumstances we are considering, may be quite short, and is to be 
commenced immediately below the cricoid cartilage. Dividing skin, 
superficial fascia, and the delicate layer of the deep fascia, we come 
upon the muscles running from the sternum to the os hyoides and 
thyroid cartilage. Seeking the interspace separating these muscles, 
they are thrust to either side, — which is easily done by using the 
handle of the knife. The thyroid plexus of veins is now brought 
into view, and is to be carried aside or ligated, as seems most con- 
venient : these manipulations bring into view the trachea with its 
rings. Take now the tenaculum, and, steadying the tube by pulling 
it upward, incise one, two, or three rings. 

The operation thus accomplished, keep the incision open by the 
use of the wire, or, if preferred, introduce the canula and maintain it 
in place by the strap, as seen in Subfig. 6, Plate VII. 

In performing the operation, it is also necessary to bear in mind 
that occasionally the inferior thyroid artery is found lying upon the 
trachea, directly in its middle line. When this vessel is seen, it 
becomes necessary to throw a ligature around it. Observations in 
the dissecting-room would lead to the inference of the presence of 
the artery in this position in about one out of six cases. 

(Edema of the glottis, a condition sometimes associated with 
acute tonsillitis, is a very dangerous complication, being found 
generally in the weak and anaemic. This complication, when really 
threatening, may be aborted by blistering the neck with cantharidal 
collodion, and afterward keeping up the watery discharge by paint- 
ing the parts with glycerine. If, however, such a treatment is not 
quickly responded to, the surgeon finds himself compelled to scarify 
the parts. Subfig. 8 represents this swollen condition of the glottis. 
To scarify these parts, seat the patient upon a chair, and, throwing 
the head well back, introduce the finger until it shall touch the 
epiglottis ; pressing now this organ toward the base of the tongue 
so that the finger shall be back of it, carry a curved and wrapped 
bistoury along the finger until it shall reach the swelling; cuts are 
now to be made from below forward. If the epiglottis is the part 
affected (and this is most commonly the case), the operation is ren- 
dered much easier; stead} T ing the organ with the finger, the part is 
to be incised as in the first instance. Subfig. 7 represents oedema 
of the epiglottis. 

Amputation of the Uvula. — Conditions requiring amputation of 



THE TONSIL GLANDS. 529 

the uvula are, relaxations of the mucous membrane refusing to 
respond to medication ; oedema, when extent of enlargement en- 
dangers life ; hypertrophy interfering with function. 

The first and second of these conditions require alone excision of 
the tip of the organ. In the first is demanded the removal of that 
superabundance of the membrane so plainly to be seen, falling life- 
lessly as it does upon the dorsum of the tongue, and being frequently 
provocative of an irritation which, without the relief of operation, 
endangers the lungs of the patient. In the second condition all that 
is required is the snipping of the slightest portion, a puncture being 
sufficient to drain away the serum occupying the cellular tissue lying 
between and associating the muscular and mucous structures. 

In the third of the conditions, a diversity in practice exists. The 
weight of experience seems to favor complete amputation of the 
organ, the objection to partial amputation being the certainty of 
regrowth. 

As one of the offices of the uvula is, however, to convey the 
mucus and saliva about the base of the tongue and epiglottis, acting 
thus as an agent of lubrication to these parts, it is objected that the 
removal of the organ results in a dryness of these parts more 
irritating than the offense removed. In hypertrophy of the organ, 
the objection, it will be seen, holds good only as absolute necessity 
for such means of cure might be in doubt.* 

* As an argument against the too free amputation of the uvula, the following 
views on the "Uses of the Uvula," by Sir Duncan G-ibbs, are to be con- 
sidered : 

" Anatomists describe the action of the uvula muscle as an elevator which 
shortens the uvula. It is, however, a sentinel to the fauces, especially in the 
act of deglutition ; for when any substance comes into contact with it, it 
excites the action of all the neighboring muscles until it is got rid of. It 
possesses a function of not less importance, in holding the soft palate tense 
and firm in the median line against the wall of the pharynx during the act 
of deglutition itself, and thus prevents the passage upward of fluid or solid 
substances behind the nose. This was supported by experiments upon a per- 
son who had lost the bones of the nose, permitting of a view of the action of 
the soft palate from its nasal aspect during deglutition, with or without food. 
Under either circumstance, a double arch was seen, in the form of two 
convex swellings held in a state of firm tension by the action of the uvula 
passing down the centre of the soft palate, with its end resting flat against the 
wall of the pharynx. The tension ceased the moment that the constrictors 
of the pharynx had fully exerted their influence over the substance swallowed. 
While the uvula has its special uses in the act of deglutition, it exerts a not 
less decisive influence upon the voice when uttered in very loud tone, or in 

34 



530 ORAL DISEASES AND SURGERY. 

Laxity of the soft palate itself is not to be allowed to deceive 
as to the condition of the uvula; persons of weakly constitutions 
being very subject to such relaxations, the uvula, while of normal 
length, dragging upon the underlying parts. Here no operation is 
required, but rather that regard and attention to the restoration of 
the lost tonicity which is the indication in all such cases. 

Amputation of the uvula is an operation of most simple character. 
Standing behind or in front of the patient, as may be preferred, the 
tongue is depressed with the handle of a spoon or other convenient 
means, when the tip of the organ, being seized with a pair of forceps, 
and dragged forward and thus steadied, is cut off at the place of 
election. 

Fig. 223.— Uvula Scissors. 




Another manner of amputation is found in the use of the uvula 
scissors (Fig. 223). This, as is seen by the diagram, consists of blades 
attached to long, delicate handles, having associated and working 
with the blades an arrangement by which as the part is cut off it 
is caught, and thus prevented from falling into the glottis. These 
scissors do away with the necessity for the use of the forceps. 

Hemorrhage from amputation of the uvula will seldom be found 
to require attention. The author has operated a great number of 
times, and never, except in one instance, met with bleeding to an 
extent requiring attention ; in this one case it yielded to a gargle of 
alum-water used once. A feeling of rawness associated with the 
excision, and which is the principal associated complaint, will be 
found corrected through the use of crystals of gum arabic held in 
the mouth, or, if preferred, jujube paste may be used, — solid food 
being excluded from the diet for a short time. 

singing the higher registers, in both sexes; then its character as a levator or 
shortener is exerted. If this power is impaired by removing the muscular 
(not the membranous) end, then the singing powers are damaged. Speech 
is modulated by the soft palate and uvula, and the motor power of the latter 
is unquestionably exerted in pronouncing the letters K, Q, and X, with their 
associations, more especially the gutturals of the various languages." 




\ 




5 



aioic 




PLATE VII. 

A VIEW OF THE OPERATIONS PERFORMED ON THE TRACHEA. 

Fig. 1. — A front view of the Surgical Anatomy of the Trachea. 1. Oshyoides. 
2. Thyroid cartilage. 3. Thyro-hyoid muscles. 4. Crico-thyroid 
muscles. 5. Thyroid gland and veins in front of crico-thyroid 
ligament. 6. Rings of the trachea. 7. Common carotid artery. 
8. Superior thyroid arteries. 9. Inferior thyroid artery. 10. 
Carotid artery, as divided. 11. Outline of the top of the chest. 
12. Innominata artery. 13. Inferior thyroid vein. 14. Trans- 
verse vein. — After Bernard and Huette. 

Fig. 2. — Relative position of the Larynx, Trachea, and Blood-vessels. 1. 
Os hyoides. 2, Thyro-hyoid ligament. 3. Thyroid cartilages. 
4. Crico-thyroid ligament. 5. Cricoid cartilage. 6. Trachea. 7. 
Internal jugular vein. 8. Transverse vein. 9. End of inferior 
thyroid vein. 10. Yeins. — After Bernard and Huette. 

Fig. 3. — Relative positions of the great vessels concerned in operations near 
the top of the sternum. 1, 1. Internal jugular vein. 2, 2. Sub- 
clavian veins. 3. Subclavian artery. 4. Transverse vein. 5. In- 
ferior thyroid vein. 6. External jugular vein. 7. Arch of the 
aorta. 8, 8. Primitive carotids. — After Bernard and Huette. 

Fig. 4. — A view of the operation of Tracheotomy, as performed by Mr. Lis- 
ton. 1. The tenaculum inserted into the trachea. 2. Position of 
the bistoury in incising the rings. 3. Line and termination of the 
external incision. — After Liston. 

Fig. 5. — Extraction of a foreign body by Tracheotomy, the head being thrown 
back and lowered, so as to facilitate the gravitation of the object. 
1, 1. Blunt hooks holding open the wound. 2. Hand of the sur- 
geon in the act of extracting the foreign body, by drawing it 
upward from the bronchia. — After Bourgery and Jacob. 

Fig. 6. — A front view of the position and mode of retaining a canula in the 
Trachea, as usually practiced. 1. The incision. 2, 2. A tape 
attached to the wings of the canula and passing around the 
neck. — After Bernard and Huette. 

Fig. 7. — The appearance of the parts concerned in (Edema of the Glottis. 1. 
The epiglottis cartilage, much swollen by serous infiltration of its 
submucous cellular tissue. — After Gurdon Buck, Jr. 

Fig. 8. — The operation of scarifying the Glottis for the relief of (Edema. 1. 
The forefinger in its position as a director. 2. The knife in the 
act of scarifying the part. — After Gurdon Buck, Jr. 

(531) 



CHAPTER XXVI. 



THE GUMS AND THEIR DISEASES. 



The gums are simply an amount of fibro-cartilaginous tissue (the 
fibrous element greatly predominating) placed as protecting cushions 
about the alveolar processes. The neck of each tooth is closely 
enveloped by the dental pits of this cushion ; the mucous mem- 
brane, which covers the common surface, being reflected around the 
pits, and rendered continuous with the periosteum of the alveoli. 

The gums, in a healthy state, are rather remarkable for their in- 
sensibility, bearing, with very little or no response, the pressure 
and irritation to which, in the process of mastication, they are so 
continuously subjected. The mucous membrane, of which this 
tissue is largely made up, is very heavy and thick as compared 
with its continuity in other parts of the alimentary canal, and is 
underlaid by a network of vessels, which leads it to be esteemed of 
considerable vascularity as reference is had to operations involv- 
ing it. 

Inflammation is the disease of the gums ; but such perverted vas- 
cular action, here, as everywhere else, has quite a variety of signifi- 
cations. These significations are — 

1. Accumulations of tartar. 

2. Periodontitis. 

3. The mercurial impression. 

4. Scurvy. 

5. Syphilis. 

6. Dead or loose teeth. 

7. A crowded dental arch. 

8. Use of improper dentifrices and brushes. 

9. Improperly inserted artificial teeth. 

10. Malignant impressions. 

11. Anomalous conditions. 

A comprehension of the diseases of the gums is found in the 
appreciation of these various conditions or influences. 
(532) 



THE GUMS AND THEIR DISEASES. 533 

1. Accumulations of Tartar. — Salivary calculus, a deposit from 
the saliva, combined with the various oral detritus, when attached 
about the necks of the teeth, necessarily becomes a source of offense, 
provoking inflammatory action, the grade of which is marked by the 
general condition of the individual. The most common type of in- 
flammation thus induced is the chronic degenerative. The tartar, 
pressing upon the gums and insinuating itself about and around the 
necks of the teeth, soon interferes to such extent with the proper 
circulation in the part as to yield the puffy, turgid condition so 
familiar in most of the cases. The mucous follicles lining the muco- 
dental pits have, of course, their secretive ability soon destroyed, and 
thus nothing prevents the insinuation of particles into these pits, 
and the consequent increase in the power of the offense. This irri- 
tation, uncombated, gradually progresses until the teeth become 
loosened and fall out, when, carrying with them the tartar, the parts 
recover. 

All deposits, however, existing under the common name of tartar 
or salivary calculus, do not have such a destructive history. Thus, 
it is very common to observe a greenish deposit, particularly upon 
the teeth of the robust and uncleanly, which, so far as I have ob- 
served, seldom results in any particular harm. Another kind, the 
black, rarely exists but in very limited amount, and as rarely or 
never does any greater ill than slightly irritating the festoon ; its 
situation is most commonly the lingual face of the inferior teeth. It 
does happen, however, that this description of tartar, or something 
very analogous to it, is sometimes provoked, as it were, in depraved 
constitutions, to extensive deposit ; it is a kind of mixture or agglu- 
tination of tartar and sordes. The gums, from a constitutional in- 
fluence very much depraved, are irritated not unfrequently by this 
jagged deposit into a state very little short of gangrene ; the breath 
is made offensive, and the oral fluids, by the admixture, are rendered 
entirely unfit to be received by the stomach. 

Yellow tartar, the deposit of the bilious and allied temperaments, 
is the kind most generally met with, and, as a rule, is most destruc- 
tive to the integrity of the teeth and gums. It is not at all uncom- 
mon to find this deposit of such extent as to inclose in a common 
mass half a dozen or more teeth, while its power of insinuation and 
destruction is so great that, before attention may have been directed 
to the process, the alveoli will be found destroyed and the teeth 
ready to drop from the mouth. I have, in my own practice, fre- 
quently been consulted in these cases, where nothing was of any 



534 ORAL DISEASES AND SURGERY. 

avail but the removal of the implicated teeth. This description of 
calculus is evidently a direct deposit from the saliva, its situation 
corresponding with the location of the salivary orifices. I think it 
will be found always associated with a sluggish condition of the 
secretive action of the glands, as I am sure its most reliable prophy- 
laxis is found in their stimulation. This tartar has a rough, dry 
surface, and is generally most easy of removal, flaking away in 
masses at the slightest touch of the instrument. The effect of its 
presence upon the gum is to force it away from the teeth, or rather, 
it might be more correct to say, to lift the teeth from the gums and 
their alveoli, destroying entirely any relation of attachment between 
the parts. The gums themselves, under its irritating influence, be- 
come puffy and soft, and occasionally so tender as to render, in many 
cases, unbearable the ordinary pressure exerted in mastication, so 
that the patient is compelled to subsist exclusively on soft food, or 
employ other than the natural process of comminution. (See chap- 
ter on Salivary Calculus.) 

2. Periodontitis. — Ulitis from periodontitis is not at all difficult 
to distinguish, and corresponds in character with the primary lesions 
in being acute .or chronic. If a tooth is acutely inflamed in its perio- 
donteum, it is sore to the touch, and elongated. If it is chronically 
inflamed, it is loose or discolored. Inflammation in the gum is 
simply an inflammation of continuity. If the patient is in good 
health, the action will be circumscribed ; if the reverse, it will of 
course influence. To treat such an inflammation, the health of the 
tooth or teeth is to be restored. An inflamed periodonteum is com- 
monly associated with a dead pulp ; this is the first source of offense 
for which we naturally look. If such a condition is found, and no 
cavity of communication exists with the pulp canal, it will, in nine 
cases out of ten, only be necessary to make such communication, and 
the trouble quickly enough disappears. Tartar is the frequent source 
of chronic periodontitis. Fish-bones, or other foreign bodies, forced 
into the membrane in mastication, excite inflammation. 

Acute periodonto-ulitis uncontrolled ends in parulis, and from such 
acute termination is very apt to pass to chronicity. Chronic ulitis 
presents the condition of continued turgescence, soreness, loose teeth, 
or fangs ; suppuration frequently occurs at the seat of the original 
abscess, and sometimes from the affected alveolar pits. Its cure, like 
that of the acute condition, resides in a treatment directed to the 
teeth. (See Periodontitis and Alveolar Abscess.) 

3. The Mercurial Impression. — Mercury first yields decided 



THE GUMS AND THEIR DISEASES. 535 

evidence of its action by producing in the mouth a metallic taste, 
complained of as coppery. A little time, and this taste is accompa- 
nied with some increase in the quantity of the saliva ; still later the 
festoons of the gums will be found congesting, commencing generally 
about the necks of the lower central teeth. Succeeding this conges- 
tion we have the dull whiteness indicating the change in the epithe- 
lial tissue (a form of aphthae). There now follow the elongation 
of the teeth, increased salivary flow, stiffness of the gums, enlarge- 
ment of the tongue, foul breath, etc. 

The effects which mercury shall produce on the mouth, or system 
at large, depend on the quantity administered and the susceptibility 
of the individual. I have myself exhibited the medicine in quantities 
of from fifteen to twenty grains in the course of three days without 
being able to perceive the local action ; while, on the contrary, I have 
known five grains so to swell the tongue that it required much effort 
to prevent the patient being smothered. Children from five to ten 
years of age have seemed to me markedly susceptible. I removed, 
a short time back, the whole of the left half of the body of the lower 
jaw, dead from but some three grains of calomel, as averred by the 
practitioner who administered the medicine. The patient was seven 
years of age. Mercurial ulitis, when confined alone to these parts, 
signifies but slight effect on the part of the action of the agent ; and 
the immediate cessation in its employment will generally result in 
the disappearance of these effects. If this should not, however, prove 
the case, I think nothing better can be done than to scarify, and 
paint the gums with tincture of iodine, graduated to each particular 
case, say, as a rule, half and half of the officinal tincture and water. 
Chlorate of potash as a wash, and used internally, may also be em- 
ployed. To an adult, ten grains of the salt, dissolved in a table- 
spoonful of water, may be given four or five times a day. As a 
local application, one drachm to the ounce of water is a very good 
strength. The bowels are to be kept in a lax condition by the ad- 
ministration of Seidlitz powders or other saline cathartics. Where 
mercurial ulitis passes to that stage which results in the breaking 
down of the tissue (and this is sometimes the case where even 
adjacent parts are not markedly affected), the treatment required is 
much more imperative, and pertains, as a rule, quite as much to the 
constitution at large as to the mouth itself. Locally, the fetor will 
urgently demand attention ; and one of the best means to correct 
this will be found in the use of a solution of the permanganate of 
potash, such solution varying in strength from two to ten grains to 



536 ORAL DISEASES AND SURGERY. 

the ounce of water. Constitutionally, vigorous tonic medicaments are 
required, — not the least important of which are the iron and bark 
preparations. If hemorrhage intervenes, it may be necessary to 
employ opium and lead internally; or, as suggested in another part 
of this work, tincture of Erigeron Canadense, in doses of one or 
two drops, repeated occasionally until such bleeding is controlled. 
Locally, cobweb saturated in alum-water may be used. Laid carefully 
upon the bleeding part, and retained in position, it will seldom be 
found to fail. Monsel's solutions should not be used. The tendency 
in extreme cases toward sloughing is a matter constantly to be 
borne in mind. When the tumefaction is very great and indolent- 
looking, the parts are still to be incised and the iodine applied ; but 
both remedies are to be used with judgment and caution. I have 
known gums in the condition alluded to, and which might perhaps 
have been recovered, sloughed in mass by applications of strong 
tincture of iodine. Always let the incisions at first be few, and the 
tincture at least two-thirds diluted. The dilute aromatic sulphuric 
acid is also a happy local remedy in these conditions. It may be 
mixed with water until the acid taste is comfortably bearable, — 
about 3j to ^viij of water. A combination for local use, which I 
also occasionally employ with much benefit, is composed as follows : 

B. — Potassae chloratis, ^ss; 
Sodae biboratis, 
Alnminis pulveris, aa 3U ; 
Potassae permanganatis, gr. xxv ; 
Aqua? Colonise, |j ; 
Tincturae cinchona?, ^ij ; 
Tincturae myrrhae, gj ; 
Tincturae capsici, 5j 5 
Tincturae kramerias, gj ; 
Aquae, ^viij. M. 

If, in defiance of all that is done, the parts should slough, one of 
three things occurs : the disease will seem to have exhausted itself, 
and the parts, after a little rest, give evidence of recovery ; or the 
bone follows the ulcerative action, and sloughs likewise; or the 
patient dies from irritation and exhaustion. (For treatment of Caries 
and Necrosis, see other pages.) 

4. Scurvy. — Scurvy proper, such as decimated the legions of 
Louis the Ninth, and in even later days was so frequently the 



THE GUMS AND THEIR DISEASES. 537 

scourge of protracted sea-voyages, is a condition which modern 
science and judgment have so combated that it may be trusted that 
few of us will ever have occasion to meet with or treat it. Modified 
forms of the disease are still, however,, prevalent enough, and exist, 
with great variety of features, from simple indolent ulitis to general 
purpura. 

Puffiness of the gums, scorbutic in nature, is fairly judged, I think, 
from its dull, purple aspect, independent of its varying constitutional 
conditions. This venous congestion compares pathologically with the 
effusions of purpura proper. It would not, however, be at all truth- 
ful, or in accordance with the facts, to describe any particular train 
of constitutional conditions as constantly associated with the scor- 
butic sore mouth, as met with in ordinary practice, and for the reason 
that nothing else of the disease may appear but the local manifesta- 
tion. That it is a constitutional affection, and not a local disease, 
is proven by the fact of absence of any source of local irritation, 
and by the further fact of its constant presence in the mouth, let 
the disease possess whatever other manifestations it may. 

Dr. Foltz, U.S.N., in a report made by him on the scurvy which 
appeared in the blockading fleet of the Gulf of Mexico, states that 
" lassitude and indisposition to muscular energy, noted so frequently 
by authors as prodroma, were not among the symptoms which 
ushered in the disease, and that there was great activity, and not 
unfrequently cheerfulness, good appetite, and sound sleep at night, 
after the teeth were loosened, the gums ulcerated, the limbs cede- 
matous and discolored ; and when at last the patient gave way, it 
was not an indisposition to corporal exertion, but an actual dis- 
ability." 

Authors, however they may disagree in their descriptions of 
such various cases as have come under their observation, are all 
agreed that scurvy results from the absence of fresh fruits and vege- 
tables, or their juices, necessary to furnish some principle required 
in the blood, and which is not, in such absence, otherwise obtained. 
In the treatise published by Dr. Hamilton on Military Surgery, the 
author says, "In regard to the pathology of scurvy, the belief pre- 
vails that it is due essentially to the absence of certain staminal 
principles from the blood, and especially potash. It appears to be 
a pretty well ascertained fact that all, or nearly all, of those reme- 
dies which have been employed successfully in the prevention or 
cure of scurvy, contain potash. Potatoes, cabbage, celery, lettuce, 
lime-, lemon-, and orange-juice, contain it in large quantity, unless 



538 ORAL DISEASES AXD SURGERY. 

their salts have been expressed by the application of heat, as in 
boiling, or other modes of cooking. Lime-, lemon-, and orange-juice 
contain nearly one grain of potash to every ounce of the juice. 

"One ounce of potatoes yields one grain and a half, while one 
ounce of rice yields only .005 of a grain. The substitution of rice 
in an English workhouse for an equal amount by weight of potatoes 
was followed in a short time by scurvy." 

In the ordinary scurvy of the gums, which every practitioner is 
aware presents itself more frequently in the very early spring, when 
the old vegetables have been pretty well exhausted and the fresh 
ones have not begun to grow, it is the common experience to dis- 
cover that the patients have existed almost exclusively on salt meats ; 
hence it is much the most frequently met with in the poorer class 
of farm-laborers. The gums, in these cases, are of a purple color, 
turgid, with the dental pits discharging pus, the teeth loosened, the 
breath offensive, but the face not by any means pale, nor the habits 
languid : indeed, there is little or nothing to signify that the local 
manifestation is a systemic offspring. When the condition is ex- 
treme, it is not uncommon to have fungoid growths springing from 
the edges and depths of the dental pits. 

Treatment. — It will be found good practice to treat these con- 
ditions locally, as directed in mercurial ulitis. Constitutionally, 
however, different indications are to be met ; a something possessed 
by a vegetable and acid diet is required by the blood. Without 
stopping to discuss the question whether this may or may not be 
potash, we act on the empirical conviction, and at once direct such 
diet. Then the depressed or perverted life-force is to be elevated or 
relieved, and to this end nothing can equal the sheet-bath, taken 
with water moderately warm and moderately salt. Saturating the 
sheet, it is quickly thrown around the body, and the patient or an 
assistant rubs the sheet over the flesh until the whole person is in 
a ruddy glow. This is repeated each morning immediately on rising. 

As medicine, the vegetable acids may be freely used. Lemonade 
is perhaps quite as good as anything that can be given. A combi- 
nation which has some celebrity is known as Turner's antidote ; it 
consists of 5ij °f nitrate of potassa, mixed in 5 viij of acetic acid, 
administered in tablespoonful doses three times a day. Conjoined 
with general medication, attention is required by the teeth and gums. 
(See chapter on Salivary Calculus.) 

5. Syphilis. — Syphilitic ulitis I judge, from my own experience 
and observation, to be an inflammation not of the gum tissue proper, 



THE GUMS AND THEIR DISEASES. 539 

but simply of its mucous envelope ; or, on the other hand, it is an 
inflammation commencing in the periosteum, and secondarily affect- 
ing the gum tissue. I do not think I have ever seen a case of 
pure uncomplicated syphilitic ulitis ; while few conditions are more 
common than mercurio-syphilitic ulitis and osteo-ulitis of syphilitic 
origin. The appreciation of such conditions is, of course, not at 
all difficult : the history of the case alone is sufficient to give the 
diagnosis, while to the experienced eye a moment's glance is enough 
to reveal such history. If the inflammation is confined to the 
mucous membrane, the full extent of its surface will be more or less 
affected, its color will be a dull red, it will be more or less tender 
to the touch, and most likely ulcerated. If, on the contrary, the 
bone or its periosteum is the primary seat of trouble, the gum may 
simply be thrown up by the effusion beneath it ; or if it happens that 
the gum itself has become inflamed, the action seems inclining to 
localize itself as much as possible. This, however, depends on the 
state of the parts beneath, and on the treatment that is being pursued. 
If the condition is one of pure uncomplicated venereal ostitis, the 
excitement in the gum will be found localized to the immediately 
overlying parts ; but if there has been a mercurial treatment, we 
may have any extent of complication. The treatment in these cases 
is to be founded on existing conditions. 

6. Dead or Loose Teeth. — Pulpless teeth affect secondarily the 
gum structure through continuity with the inflamed periodonteum. 
A tooth periosteally inflamed is always sore to the touch, is more or 
less elongated, and is discolored. A ulitis connected with such dis- 
eased tooth or teeth is plainly discoverable by the absence of other 
sources of irritation ; relief follows, of course, the cure of the primary 
lesion. 

*l. Overcroivded Condition of the Dental Arch. — See chapter 
on Anomalies of Dentition. 

8. Use of Improper Dentifrices and Brashes. — Many gums 
are subjected to continuous irritation and inflammation from the use 
of agents in the way of dentifrices, brushes, or other dental applica- 
tions, which, either chemically, vitally, or mechanically, predispose 
and excite to deterioration. Perhaps in the whole range of practice 
there is, in no single instance, less attention given to the require- 
ments of the various cases than is manifested in the prescribing of 
tooth-cleansing powders and washes. . Charcoal, a favorite agent 
with many, while excellent in its place, is one of the most frequently 
abused of these remedies. Very common is it to find, after a few 



540 ORAL DISEASES AND SURGERY. 

weeks or months of the nse of this material, the gums becoming 
pitted with black spots about the necks of the teeth and loosening 
from them. This is a result of the insolubility of the agent in the 
fluids of the mouth ; gradually, but surely, it finds its way into 
the mucous pits, and, not being either washed out or dissolved 
by the secretion, it quickly destroys the integrity of the relation; 
hence follow chronic periodontitis and the eventual loss of teeth, — 
the mass of gum tissue sympathizing during the whole period, 
producing chronic ulitis. 

Pulverized coral and pumice are other agents mechanically de- 
structive, although in their places very good, and, as will be re- 
marked, recommended. Castile and other soaps, too freely used, 
degenerate by the action of their alkalinity. A constant use of such 
agents is quite certain to be attended by puffiness and chronic 
turgidity of the gums, by degenerated mucous discharges, and by 
an offensive breath. Acids, on the other hand, employed of too full 
a strength, inflame and irritate the gums, and put the teeth on edge, 
by dissolving more or less of their lime salts. A ulitis from the irri- 
tation of acid agents differs, however, from that produced by the 
alkaline, in being of a free, generous, acute, or, at worst, subacute 
nature, easy of control, and much more injurious to the teeth than 
to the gums themselves. Irritation of the gums commonly asso- 
ciates also with injury to the teeth. 

A very common cause of ulitis in persons with carious teeth 
results from the too free use of creasote. This agent, used pure, is 
a powerful irritant, and has been the cause of some of the most 
severe acute inflammations. Seen early, the cases exhibit the direct 
effect of the agent in the escharotic result that has been produced 
on the mucous membrane, — this being white, pasty, and sloughing. 
Outside of the immediate local use of oil or butter, if it is inferred 
that free creasote remains about the mouth, such cases are to be 
treated on common principles. A case occurred, a short time back, 
in my own practice, where a girl, with the intention of committing 
suicide, swallowed two drachms of the agent. Called immediately, 
I used as an emetic the first thing at hand, namely, the soap on her 
washstand, and followed the emetic with half a pound of common 
table-butter. No particular bad results occurred : the patient's 
mouth, oesophagus, and stomach were sore for three days, after 
which she seemed about as usual.* 

* Dr. Theodore Husemann [Journal of Applied Chemistry) " opposes the use 
of fixed oils, glycerine, and similar demulcents in cases of poisoning by carbolic 



THE GUMS AND THEIR DISEASES. 541 

Chloride of zinc, used in the mixing of the so-called bone-plugs 
now so freely employed with the teeth, is another of the causes of 
ulitis. Its action may be of a twofold character: either directly 
upon the gum tissue, as by its careless use it may have been allowed 
to come in contact with this structure, or through a periodontitis 
excited by the action of the agent on the dental pulp. From abuse 
of this agent many cases have occurred in which large portions of 
the gums are destroyed ; and not unfrequently the action extends 
to the alveolar process, necrosing the sockets of the teeth. 

A cause of chronic ulitis, which has been occasionally met with, 
consists in a wedge of gold or other metal forced into the dental pit 
while in the act of filling a tooth on its proximal face. A matter 
of this kind is very apt to be overlooked by the general practitioner ; 
hence an unappreciated stubbornness in his case. When ulitis is 
circumscribed, and the centre of the trouble seems to be a tooth 
filled on a proximal surface, attention may be first directed to such 
a condition. Let the practitioner take a strand of common ligature 
silk, and, passing it between the teeth, feel if it runs freely about 
the necks; if it should catch, the probability is he has discovered 
the trouble. 

The too free use of arsenical paste in the destruction of the dental 
pulp is a frequent source of ulitis. I have seen two or three very 
severe cases from such a cause. In the use of this remedy, it is in 
every instance well to cover it in the cavity with a particle of wax, 
or, where this is not admissible (and there are certainly many cases 
where it is quite impossible), then a tuft of cotton, saturated with 
gum sandarac, is placed over the application, and protected for a 
few moments until it hardens. (See Odontalgia.) In inflamma- 
tion from this cause the immediate local use of the sesquioxide of 
iron has been recommended ; but, personally, I have seen no good 
results from it, the harm being done before the patient applies. 

acid or creasote, but recommends, based upon experiments with rabbits made 
by himself and Ummethun, the saccharate of lime, the alkaline earth com- 
bining with the carbolic acid to form a non-irritating salt. Lime-water is 
less adapted to this purpose, owing to the sparing solubility of lime in water, 
and the large quantity of lime-water required for neutralizing the poison. 
Precipitated carbonate of lime does not combine with carbolic acid, but may 
be employed in case the saccharate of lime should not be procurable at once; 
the carbonate appears to act merely mechanically by absorbing the poison, 
and thus delaying its ill effects ; sufficient time is thereby afforded to prepare 
the saccharate." 



542 ORAL DISEASES AND SURGERY. 

Syringing the parts thoroughly, and a treatment directed on general 
principles, is all that can be done. 

Brushes used in cleansing the teeth are frequently a source of 
offense from their excessive stiffness, really tearing the epithelium, at 
each cleansing, from the mucous membrane ; the patient complains 
of the soreness and bleeding of the gums every time the teeth are 
brushed, yet seems to fail to recognize that he himself produces 
the trouble. 

9. Improperly inserted Artificial Teeth. — Ulitis, resulting in 
fungoid degeneration, and in the most troublesome of chronic condi- 
tions, is frequently witnessed as the result of ill-adapted dentures 
and of unsuitable material employed in their construction. Teeth 
inserted on plates held in position by clasps or bands attached to 
certain teeth, are a prolific source of offense. Where the bearings 
of a plate are not accurate, the bands cut into the gum fret and 
irritate them, until, in the end, the teeth to which the clasps are 
attached are loosened, and the gum passes to a chronic degeneracy, 
and puffs up, losing much of its vitality ; otherwise a hypertrophied 
ring of the tissue, hard and callous, surrounds the diseased tooth, 
and serves as a sort of protection to the adjoining parts. A case just 
now comes to my mind in which a lady, wearing an upper set of 
teeth, supported partially by atmospheric pressure and partly by a 
band passing around the only natural tooth in her mouth, had pro- 
voked, in this socket, an epulic growth of such threatening charac- 
ter that, failing to cure it by ordinary means, I felt compelled to 
advise an operation as the only hope of saving her life. Epithelioma 
I have also seen located by a similar cause; having had, in my 
own practice, the misfortune to lose one such case. In Mr. Heath's 
Jacksonian prize essay, drawings are given of certain papular hyper- 
trophies (thought by the author to be quite rare specimens) on the 
oral mucous membrane. These hypertrophies I have frequently 
seen on the membrane beneath the cavities of suction plates ; they 
look like enlarged and indurated fungiform papillae. Another form 
of such hypertrophy is induration of the membrane in full, lying 
beneath the cavity ; the parts are raised by sub-effusions, which 
organize and become as hard almost as cartilage. Still another 
form is the rugose, — several wheals running across the space ; these 
indurations I have never known to do any harm. In some instances 
they remain permanent after the removal of the offense ; but, as a 
rule, they will be found to disappear in a few months after a plate 
is taken away: indeed, I met one lady having these hypertrophied 



THE GUMS AND THEIR DISEASES. 543 

papilla?, who told me she had had them for over a year, and had 
never ceased to wear her plate. 

Hypertrophy of the gum in mass occasionally results from the 
mechanical irritation of dental plates. I am, at the time of writing 
this, treating a lady suffering under such an enlargement ; the trouble 
is in the upper gums, and they seem like thickened masses of gristle, 
and, I am sorry to say, prove about as insensible to medical 
impression. 

Vulcanite, a material much employed in the construction of dental 
plates, is to many mouths a source of unbearable offense. The 
cases that have come under my own observation have been all alike, 
— soft, flabby, relaxed, congested, and very sluggish in recuperation, 
the gum tissue seeming to be softened from surface to base. Acid 
and astringent lotions are best adapted to the cure. 

Silver is another material that it would perhaps be as well to 
dispense with in the construction of dental appliances ; also gold 
too much alloyed with copper, running down, as it is sometimes 
found, to fourteen carats. 

10 and 11. In other parts of this work occasion is taken to treat, 
under what are deemed to be proper heads, various conditions, com- 
monly associated under the common appellation of gum diseases, 
as, for example, the epulic growths, considered in a succeeding 
chapter. 

Observation of Fig. 224 exhibits a congestion which has swollen 
the gums and tissues of the hard palate to an extent which conceals 

Fig. 224. — View of Gums Inflamed by Vulcanite Plate. 




almost completely three posterior teeth which remain in the parts. 
The patient from whose mouth the drawing was made had worn a 
plate of vulcanite nine months ; the parts were a dusky red, — flabby, 



544 ORAL DISEASES AND SURGERY. 

relaxed, and exceedingly indolent. There was no particular com- 
plaint of pain, — simply a soreness, together with a tenderness on 
pressure, which tenderness had increased gradually until the removal 
of the piece became a necessity. The cause of irritation from these 
plates is variously considered : the most likely, however, is the very 
complete exclusion of atmospheric air, and the consequent heating 
which follows. To cure such cases it will be found, in most in- 
stances, a necessity to remove the denture, after which stimulating 
and astringent gargles may be prescribed. 
A very excellent combination is as follows : 

R. — Aquae Coloniae, §j ; 

Tincturae capsici composite, 3j ; 
Sodae biboratis, 3lj 5 
Tincturae cinchonae, 
Tincturae pyrethri, aa gj ; 
Aquae, ^vj. M. 

A second application, which justly receives much commendation, 
is the following : 

R. — Aluminis sulphatis, gr. x ; 
Acidi tannici, gr. xx; 
Glycerinae, gj. M. 
To be brushed over the parts. 

Cases of hypertrophy from ill-fitting clasps or ill-fitting plates are 
not unfrequently met with ; sometimes such an induration will be 
found circumscribing a single tooth to an extent which half conceals 
it, the band being accommodated in a space existing between the 
gum and tooth. I have known such cases to give much concern by 
the obstinacy of their persistence after the removal of the cause of 
offense ; but such anxiety is seldom well founded, for even should 
the induration remain it will exhibit no tendency to degenerate. In 
the treatment it is only desirable to remove the offending band, and 
leave the case to nature. 

As general hypertrophy of the gums is concerned, I might illus- 
trate the condition by referring to a case at present under treatment. 
The patient, a lady in fine health, middle-aged, wears a plate of gold 
containing seven scattered teeth. Wherever this plate bears, the 
parts are enlarged, indurated, and scirrhus-like. If it were not for 
the absence of the associate expressions of carcinoma, one might 



THE GUMS AND THEIR DISEASES. 545 

very readily infer tbe presence of such disease. The explanation of 
such induration is to be found in an imperfect adaptation of the 
denture, conjoined, perhaps, with a cachexia. The treatment has 
been the very simple one of advising the patient not to wear the 
plate, nor any other, until a cure is obtained. No medication has 
been deemed necessary. 

Still another class of cases exists in the hypertrophy of the 
mucous membrane lying beneath the surface of suction cavities. 
Sometimes this surface will be found simply thickened and hard- 
ened ; at other times it will be seen broken into deep fissures ; still 
again it is observed studded with papillae, fungiform in character, 
and not unfrequently possessed of a tendency to hemorrhage. I 
have met with these various cases where quite serious results 
seemed threatened, although never except in a single one did any 
ill consequences ensue. In this one case necrosis of the underlying 
bone exposed the nares. 

Treatment. — This is generally to be tentative ; the plate must 
be removed, or at least the suction cavity must. If the parts do not 
recover after such removal of the offense, it may be found desirable 
to touch with zinc, iodine, or capsicum. If caries or necrosis 
should ensue, such condition is to be treated as referred to in the 
chapter on these diseases. 

Fig. 225 exhibits a form of general hypertrophy of the gum struc- 
ture occasionally to be met with. Such conditions are oftentimes 
found to be but expressions of unobserved 
local agents of offense, upon the removal ^ IG - 2 ^5. 

of which the overgrowth will disappear. 
Where, on the contrary, the hypertrophy is 
seen to be an expression of a constitutional 
condition, the observable vice is to be cor- 
rected. The best local treatment consists 
in frequent incisions through the parts, 
and the application of tincture of iodine. 
Removal of the overgrowth by the knife 

is Seldom, if ever, found to be COllipen- ^^ of Case of General Hyper- 
Sating. 

Fig. 226, a case of chronic ulitis, with recession, is a type of a 
very common condition, and has a great variety of meanings. The 
principal cause of such recession is found, according to my own 
experience, in the accumulation of small quantities of tartar just 
below the free edge of the gums. A second cause, and a very 

35 




546 ORAL DISEASES AND SURGERY. 

prominent one, lies in a solidification of the tooth structure, — the 
equilibrium of circulation existing between the tooth pulp, periodon- 
teum, and gum being thus disturbed. Causes strictly local, how- 
ever, need only give concern, as they affect the appearance of the parts 
and the health of the teeth ; they are susceptible of remedy, re- 
quiring only attention and the proper skill. It will be readily 
inferred, however, from what has been said on previous pages, that 
local lesions are not alone to blame for such conditions. " In forming 
a judgment," says Mr. Bell, "upon cases of this description, and even 
upon those in which the loss of substance is associated with more 
or less of diseased action, it is necessary to recollect that the teeth 

Fig. 226. — View of Chronic Ulitis, with Kecession. 




in old age are removed by this identical process, — namely, the 
destruction of their support by the absorption of the gums and 
alveolar processes ; and as this step toward general decay com- 
mences at very different periods in different constitutions, it may, 
doubtless, in many cases, even in persons not beyond the middle 
period of life, be considered as an indication of a sort of premature 
old age, or an anticipation at least of senile decay, as far as regards 
these parts of the body." 

In depressed conditions of the life-force, as witnessed in the 
habitual drinker and debauchee, such recession is generally found 
conjoined with suppuration, and affects all the parts alike; the gums 
are turgid, sluggish-looking, and more or less purple ; the mucous 






THE GUMS AND THEIR DISEASES. 547 

membrane lining the mouth and throat is of a dirty red ; the tremor 
and prostration of the system at large show the constitutional 
nature of the offense. 

Another form of this recession is associated with the sickly and 
weak ; here, however, the part is even lighter than in health, is 
shriveled and shrunken, clasping the neck of the tooth tightly and 
closely, — seeming, indeed, shrinking within itself. These cases are 
always anaemic, being found usually in the female sex, or in males 
inclining to phthisis. Everything that tends to induce such a con- 
dition may be regarded as a predisposing cause : such are bilious 
and inflammatory fevers, the excessive use of mercurial medicines, 
the venereal virus, anything tending to the deterioration of the 
fluids of the body. Persons of cachectic habit are far more subject 
to it, and generally in its worse forms, than individuals in the en- 
joyment of good health. Because of the truthfulness of such 
assumptions it is seen that the condition is an occasion of warning. 
In my own experience, I have not unfrequently recognized that such 
a recession of the gums was a first indication of declining health. 

Treatment. — This is of course to be directed to the cause. Where 
this shall be found to be of a strictly local nature, most excellent 
effects are occasionally secured by scarifying the affected gums three 
or four times a week, and touching them lightly with chloride of 
zinc, a solution in strength of about grs. xx to water §j. Some- 
times, and I have occasionally succeeded much to my satisfaction, 
the edges may be pared and brought together with a single stitch ; 
this little operation, however, only appljes where the tissues are 
reasonably loose and fairly healthy, and the recession is Y-shaped. 
Compound tincture of capsicum is an excellent provocative of gran- 
ulations ; iodine also acts happily. The parts are always to be 
scarified to allow such applications to be of any service. The vari- 
ous washes recommended are, of course, useful or not so, according 
as they may be adapted to the peculiar indications : of these, the 
stimulating and astringent will be found most frequently demanded. 
Where the teeth are thus exposed without apparent lesion, either of 
a local or general nature, the trouble is to be deemed incurable. 

Congenital Union of Gums. — Dr. W. S. Carter reports the follow- 
ing anomalous case, which, with a few others,' is presented as an 
interesting study in this direction of oral troubles: "Mrs. W. was 
delivered, after an easy labor at full term, of a living male child. 
' The infant was perfectly quiet for a few moments after its birth, and 
then spasmodic respiratory efforts were made. Thinking the throat 



548 ORAL DISEASES AND SURGERY. 

might be obstructed by mucus. I endeavored to introduce my finger 
to remove it. The finger passed readily between the lips, but, to my 
astonishment, I could get it no further than the gums, which both by 
sight and touch I found firmly united. 

''As it was necessary to act promptly, I immediately, with the 
assistance of my partner, Dr. Tilford, divided the tissue uniting the 
gums. This appeared to be about as thick as the gums, and was 
cartilaginous, extending as far back on either side as the angle of the 
jaw. Notwithstanding this free division, which enabled the child to 
breathe with more facility, the jaws were immovable. 

•'After letting the patient rest a few hours, Dr. Sellers, of Browns- 
burg, visited the patient with me ; and it was decided to use some 
force to separate the jaws, and make a further careful exploration. 
This exploration showed us a tough membrane, one-eighth of an inch 
in thickness, passing from the palate bone above, and inserted into 
the lower gum. Upon the division of this and the use of some little 
force, the jaws were separated. 

" In two weeks the gums had healed, the child took nourishment 
readily, and was doing well. 

"Other malformations also existed in this case: viz., the fingers 
and toes were webbed, and the ears were in rather a rudimentary 
condition — the integument passing from the head over the anterior 
surface of the upper third of each of these. 

"When the mother was about three months pregnant, her son, 
about six years of age, had a severe convulsion, the jaws being spas- 
modically closed. She was alone at the time, and her terror was 
excessive ; and, indeed, since then, during all the remaining months 
of her pregnancy she states the frightful scene has scarcely ever 
been absent from her mind." 

" We have delayed," remarks the editor in whose journal this in- 
teresting communication appears, "for some weeks the publication of 
Dr. Carter's extraordinary case, in order that we might, if possible, 
find recorded some similar cases or case ; but after a diligent search 
we have been utterly disappointed. Even Saint-Hilaire, to whose 
study of the various anomalies of organization science is so greatly 
indebted, fails us in presenting any analogous instance. 

" While almost any one of the external openings of the body may 
be imperforate, yet this condition much oftener affects the inferior 
than the superior orifices of the trunk : e.g. closure of the anus as a 
congenital condition is more frequently met with than closure of the 
eyelids, closure of the vagina than of the external auditory meatus. 



THE GUMS AND THEIR DISEASES. 549 

" In regard to congenital adhesions of the mouth hitherto de- 
scribed, they have been from adherence, sometimes complete, in 
other instances partial, of the lips. Even this malformation the 
illustrious Boyer spoke of as a possibility, never having seen it ; but 
Yelpeau discovered that Haller had pointed out its occurrence in the 
human species and also in the inferior animals, that Schenkius had 
met with cases upon which he had to operate, and that Desgenettes 
had seen a seven months' foetus with imperforate mouth. 

" In Saint-Hilaire's work, chapter iii., Des Anomalies par Con- 
tinuite des Parties ordinairement disjointes, section i., Des Anoma- 
lies par Im perforation, will be found the following, which may be 
of some interest in connection with Dr. Carter's report: The imper- 
foration of the nares is much less frequent than that of the eyelids; 
nevertheless, Littre and Jean Bianchi have seen it in subjects in 
whom. other irregularities also were found, and Oberteuffer has also 
several times observed the same condition. 

" In the case mentioned by Littre, the closure of the nares was 
complicated with closure of the mouth, the skin passing over both 
apertures, an anomaly of still less frequent occurrence. The closure 
of the mouth has also been seen where the nares were unobstructed, 
but these cases presented various other deviations also. 

" As to the possible influence of the sudden and severe terror to 
which the mother was subjected, which Dr. Carter mentions, in 
causing the malformation, it probably is better neither to affirm nor 
still less to deny. Certain it is that the tendency of the observant 
and thoughtful in our profession is not to reject as ' old wives' fables' 
all that is told us of the very strong influence of maternal impres- 
sions upon the foetus, fables which have so long found such genera 
credence with mothers and with the public. Those who are inter- 
ested in the study of this question will find an admirable and philo- 
sophic discussion of it, by Dr. Alfred Meadows, in the seventh 
volume of the London Obstetrical Society's Transactions. It occurs 
in connection with the report of a case of Monstrosity, given by 
Dr. M., the mother attributing the deformities of her offspring to 
the fact that during the earlier weeks of her pregnancy she was 
greatly horrified by being shown some of Aristotle's plates, in which 
were exhibited some deformities resembling this, and specimens of 
other monstrosities." — Western Journal of Medicine. 

" Stomatitis and Pharyngitis Leucsemica. — In Virchow's Ar- 
chives, Dr. F. Mosler relates the case of a male forty years old, and 
previously of sound health, in whom, in the course of some fifteen 



550 ORAL DISEASES AND SURGERY. 

months, there took place gradually a swelling of the glands on both 
sides of the throat, attended with inflammation of the mucous mem- 
brane of the mouth and pharynx, with flaccidity of and hemorrhage 
from the gums, followed by swelling of the axillary and inguinal 
glands, and finally of the liver and spleen. There was now an 
evident increase in the white particles of the blood. In the case 
described, the only etiological agent to which the morbid phenomena 
it presented could be referred was inordinate exertion of mind and 
body. The condition of the throat was of especial interest. Its 
mucous membrane was red and swollen, and over its surface there 
were spread numerous medullary elevations having a smooth 
shining appearance. Both tonsils were enlarged, and their surfaces 
presented the appearance of a congeries of large, dense, medullary 
knots. The secretions of the surface of the mouth and larynx and 
of the salivary glands were greatly increased by talking. After a 
thorough rinsing of the mouth, its secretions gave an acid reaction. 
The patient had not suffered previously from any disease of the 
mouth or throat. The patient was attacked with this only after the 
lymphatic glands of the neck had become enlarged, and, at first, 
with their increase or diminution the throat affection became worse 
or better. Finally, under the use of quinia and iron, remedies 
which exerted a beneficial influence on the entire morbid phenomena, 
the patient got well. Dr. M. believes that the form of stomatitis 
and pharyngitis here described is a specific disease resulting from a 
leucaarnic dyscrasy. The inflammation of the mouth, which in its 
symptoms had a close resemblance to scorbutic stomatitis, was 
probably caused by an irritation due to some morbid chemical product 
in the blood and the secretions of the lymphatic glands, by which, 
also, according to Dr. M., is to be explained the affection of the 
mouth met with in cases of diabetes, the nature of which is still, 
however, unknown." 

" Blue Line in Saturnine Affections, and its Pathognomonic 
Value. (Archives de Medecine Navale, and Gazette Hebdomadaire.) 
— Dr. Falot refutes the authors who believe that the blue line along 
the gums is formed by an accidental deposit on the buccal mucous 
membrane of lead furnished by dust contained in the air or food, or 
still more in fluids that have been adulterated or" accidentally charged. 
According to M. Grisolle, among others, the blue line is the livery 
of the lead-worker, not a symptom of poisoning, but a simple 
deposit, and a sign of the worker's occupation. M. Falot quotes 
the observations of Beau, Barlow, Gregory Smith, and Lecoq, all 



THE GUMS AND THEIR DISEASES. 551 

of whom observed the blue line in patients undergoing an internal 
treatment with pills of subcarbonate or acetate of lead; and he 
gives, in addition, the reports of some cases of his own, which were 
gathered in an epidemic of colic in a ship's crew at the Gaboon, the 
cause of which was lead-poisoning. Finally, after having estab- 
lished by experiment the impossibility of reproducing the blue line 
artificially by touching the gums corresponding to the incisor and 
canine teeth of the lower jaw with a brush dipped in acetate of 
lead, and after having proved that oxygenated water, and water 
sharpened by sulphuric acid, the ordinary reagents of lead, had no 
influence upon the blue line when it is plainly established, Dr. Falot 
proves that the line is the result of an elimination of the lead, and 
indicates by its manifestation that the lead, carried along by the 
circulation, comes to be deposited in the tissue of the gums, where 
it forms a combination which reveals its presence by a more or less 
intense blue coloration. M. Falot finishes his contribution by 
representing the blue line as a sign of penetration of lead into the 
economy, and he derives the important conclusion for forensic 
medicine, that its presence may denote lead-poisoning, although an 
analysis of the viscera may not have revealed the smallest trace of 
the metal." 



CHAPTER XXYII. 



CARIES OF THE MAXILLA. 



Caries of bone, practically viewed, is a disease very analogous 
to ulceration in the soft parts, and is possessed of the threefold ex- 
pression of simple, strumous, and specific* As the jaws are con- 



* " There was a time when the conception of caries was very comprehen- 
sive. Wherever, by pathological changes, a corroded, disorganized condi- 
tion of hone had been occasioned, the term caries was applied ; in this sense 
we might speak of cancerous and syphilitic caries, we might term the de- 
ficiencies of bone caused by aneurisms caries, etc. At present we confine 
ourselves more and more to so naming two forms of actual ulceration of bone, 
the one simple, the other fungous caries. Simple caries corresponds to what, 
upon the skin, we would call an indolent ulcer, — a loss of substance at the 
surface of a bone, slowly going deeper, upon the whole, however, shallow, 
upon whose base small amounts of pus, together with breaking-down remains 
of tissue, are continually separated. The pus, as in general all fluid con- 
stituents of the secretion, is produced by the exposed medullary tissue. This, 
at a certain distance from the surface, is in a hypergemic, hyperplastic con- 
dition, which, toward the surface, gives place to an extraordinarily dense 
cellular infiltration. The cells fill up all the pores of the osseous structure com- 
pletely : they leave no space for blood and blood-vessels ; the latter are com- 
pressed, and then together with the cells themselves go over into a molecular 
detritus. The latter not unfrequently forms an uninterrupted, most super- 
ficial layer, which naturally only obtains support and adheres because it is 
penetrated by the trabecule of the spongy substances not yet destroyed and 
connected net-formed. The interference of the osseous tissue in the inflam- 
matory process has consequently a decidedly injurious influence upon its 
course. It is the osseous tissue which, upon the one hand, by refusing space, 
makes impossible the free development of a healthy granulating surface and 
lets the cell-formation smother in its over-exuberance ; upon the other hand, 
however, by the persistent connection with the healthy bony trabecular of the 
deeper layers, holds fast the breaking-down, putrefactive material, which had 
better have been separated and cast off long ago, like a slough upon the sur- 
face of an ulcer, and thereby impress upon the entire process the character of 
an indolent ulceration." — Kindfleisch. 

" Chronic ostitis or caries is a chronic inflammation of the connective tissue 
in the bone,, with consumption of the latter. If from a carious spot we 
(552) 



CARIES OF THE MAXILLA. 553 

cerned, the condition is confined almost exclusively to the superior 
bones. The causes which act as provocatives are, of course, various ; 
yet dead teeth and roots of teeth will be found far to preponderate. 

remove a particle of bone and look at it under the microscope, we will in 
many cases see its edges and surface bitten out, as it were; the bone-corpus- 
cles being unchanged ; the intercellular substance somewhat more cloudy 
than usual," perhaps, but not much altered. A section of bone taken from 
the vicinity of such a carious spot, shows nothing different. If we saw or 
cut out a piece from a carious spot and abstract the chalky salts from the 
bone by chromic acid, and then make section through it and clear them with 
glycerine, we will see these bitings, as it were, quite regularly along the 
edges, with young neoplasia growing into the defects, while able to observe 
that the further increase of them goes hand-in-hand with the dissolution of 
the bone; the bone-corpuscles are unchanged, no destruction starts from 
them. We occasionally see them half destroyed at the edge of a piece of 
the bone. "What becomes of the cells that were in them, we can hardly say; 
they can no longer be recognized among the numerous young cells of the 
inflammatory new formation among which they enter : it is possible that, freed 
from their cage, they aid in increasing the cell-brood by subdividing ; possi- 
bly they die; at all events, so far as may be judged by the change of form, 
they do not aid in dissolving the bone. But how the bone is dissolved remains 
an unsolved riddle. 

" One point, however, we must consider. It would be very supposable that 
the bone-substance, having its nutrition affected, would begin to break up and 
crumble into very fine particles or powder ; this would be especially apt to 
occur if the bone had previously lost its organic substance. It could even 
be shown that this is the primary step in ulceration of the bone or caries, and 
those who regard destruction of tissue as the primary step in ulcers of the 
soft parts, and inflammatory new formations on the second, will also hold 
this view in regard to bone. Observation, however, speaks very decidedly 
against the universality of this view of ulceration, for what is not found 
proven as concerns the soft parts, cannot be considered true as regards the 
bones. But there is no doubt that portions of bone may crumble off, and, 
when there is suppurative ostitis, these small particles of bone may be found 
in the pus. This would be a necrosis of the lowest form; such a death of 
the particles of tissue also occurs in the soft parts, both in acute and chronic 
inflammation. It cannot be considered as a rule in caries : it is only seen 
occasionally in caries with suppuration or caseous degeneration. Here even 
large portions of bone may actually become necrosed, and for this combina- 
tion of caries and necrosis we have the curious name caries necrotica. 

" In the soft parts is to be seen the development of the process of ulceration 
in a fungous ulcer when the productive character predominates. This has its 
analogy in bone, in ostitis fungosa, where there is yet no destruction of the 
inflammatory new formation, but where interstitial granulative tissue has 
grown all through the bone. If one remembers the atonic, torpid ulcer of 
the soft parts, and recalls how the neoplasm rapidly breaks down into pus, 



554 ORAL DISEASES AND SURGERY. 

Caries of the jaw presents commonly, yet it may be in aggravated 
form, the external features which characterize the ordinary alveolar 
abscess, whether in its acute or chronic forms. This, however, 
would be inferred, such lesion being so commonly its origin. When 
the attack is acute in its nature, ulitis or periostitis will always be 
found associated with it. If the disease originates as a pure ostitis, 
then the gum in turn quickly sympathizes ; if, on the contrary, the 
inflammation arises from a tooth, periodontitis will distinguish the 
offending agent. In all inflammations about these parts, whatever 
their character and cause, the abortive treatment cannot too quickly 
be attempted. From failure to attack with sufficient vigor such in- 
flammations, I have not unfrequently known the whole bone to be 
destroyed. 

Caries once established, a diagnosis is made easy through the in- 
strumentality of the sense of touch. One or more fistulous openings 
will be found to exist in the gum, or it may be in some neighboring- 
part, the orifices of which are surrounded commonly by fungous 
granulations ; through these sinuses it is only necessary to carry a 
probe, when the bone is found riddled, honeycomb-like, and easy to 
break down, either as the surface is implicated, or as in the stru- 
mous expression of the disease the deeper parts are involved. In 
such examinations it will always be found advantageous to replace 
the ordinary probe with the common dental excavator, as otherwise, 
from the less accurate touch attained through the first instrument, 
it is possible to mistake the denuded bone of ordinary alveolar 
abscess for the more formidable and extensive disease, thus being 
misled as to the treatment required. In carrying the instrument 
through the opening of an alveolar abscess, it is remarked that the 
bone is denuded ; but the touch differs from that peculiar to caries, 
in the fact of this denuded bone being hard and resisting. Not 
always, however ; for it has just been remarked that periodontitis 

undergoes caseous transformation or disintegrates, and simply applies the 
same change to bone, he will readily understand the case ; this also gives 
caries another character. There are very torpid, atonic forms of caries where 
the neoplasia causes hut little destruction of bone, and then disintegrates or 
undergoes caseous metamorphosis, and then in the living organism there is a 
sort of maceration of the diseased bone : the soft parts in the bone suppurate. 
If this happens before the bone is dissolved, the portion of bone that has 
suppurated is necrosed. Here, also, most of the fault of the disintegration is 
due to deficient vitality. But we must look to constitutional influence why 
we have in one case fungous or proliferating, in another atonic caries." — Bill- 
roth. 



C ABIES OF THE MAXJLLJE. 555 

and alveolar abscesses are the most common causes of ostitis and 
caries, reference being had only to the pure, uncomplicated cases of 
alveolar abscess. As a rule, when a sharp instrument introduced 
can be made to pass readily into the substance of the bone, and to 
break it down, caries is present, If, on the contrary, the bone is 
solid and resisting, even although denuded, caries does not exist. 
Carious -bone is frequently, however, found associated with exu- 
berant granulations, which deceive when the probe used is not of 
sufficient sharpness readily to penetrate the fungus. As a rule, no 
harm is found to result in boldly thrusting knife or probe through 
soft parts inferred to mark maxillary disease. 

An ostitis, however provoked, does not by any means necessarily 
run into osseous ulceration, any more than ulceration is necessarily 
a result of an inflammation in the soft parts. There are, however, 
certain conditions which markedly predispose to such ulcerations : 
of these the strumous is without doubt the most marked. The 
bones of scrofulous subjects break down easily, also those of per- 
sons who have received the mercurial impression. Cancerous 
caries of the upper jaw is not unfrequently to be met with ; while, 
aside from such conditions, it has seemed to my experience to be 
true that, in persons of the most robust and vigorous health, a 
slight cause has been sufficient to develop the disease. A case this 
moment recalled (a very marked one) will serve to illustrate the 
probability. 

In the autumn of 1867 a gentleman from a distant State visited 
Philadelphia for the purpose of having an opinion concerning a 
fistule that existed over the apex of the right upper lateral incisor 
tooth, and which had long resisted the ordinary applications and 
injections used by his professional adviser at home. This fistule had 
originated from the lateral tooth, which was a dead one, and was 
considered simply an alveolar abscess, the only question thought to 
be involved being the loss of the tooth, which the patient was most 
desirous to save. The gentleman coming first under the care of a 
personal friend, I had an opportunity to see him in consultation, 
when examination revealed a softened, honeycomb-like condition 
not only of the right but also partially of the left jaw, necessitating 
an operation of very extensive character, so far as the removal of 
softened bone was concerned. 

In this case I failed to recognize anything wrong with the general 
health of the patient, in which opinion I was joined by his profes- 
sional adviser, the person being young, and of more than commonly 



556 ORAL DISEASES AND SURGERY. 

vigorous habits. The primary lesion here was, without doubt, the 
dead lateral incisor. Why this should have provoked such exten- 
sive disease I am at a loss to say. In this particular instance, as 
in many cases, the disease was developed and advanced without 
any very marked acute manifestations, a not uncommon feature in 
caries, and one which is of much importance to be borne in mind. 
A whole jaw may be softened and destroyed, while the patient rests 
under the false impression that he has no trouble that is beyond 
cure through the loss of a tooth. I have occasionally met with 
cases of this kind, where the adviser and the advised have been alike 
deceived. 

The slowness or the rapidity with which caries of the jaw pro- 
gresses is influenced by individual conditions. Thus, in the periods 
of dentition, the disease will commonly be found to make rapid pro- 
gress, unless, indeed, the vital forces are very resistive ; while in 
the mercurially weakened bone, caries seems sometimes analogous 
to a simple mechanical disintegration, as if, indeed, the particles of 
bone had lost the power of cohesion. 

The peculiar affinity existing between this disease and the cellular 
tissue of the bones leads to the inference that it is more common to 
persons whose skeletons are loose and spongy in character than to 
the reverse class ; and this is markedly true : hence strumous chil- 
dren are very subject to caries, as is so often witnessed in their 
articular complaints. 

In many subjects the condition seems to be that of a semi-fatty 
degeneration, the animal portion of the bone becoming quite soft 
and greasy ; indeed, even the osseous particles thrown off present 
the same aspect. The relationship of the disease with tubercular 
deposits is so fully established in the minds of many that they 
incline to the conviction that such tubercle is present at all points 
of the manifestation of caries. That this is not fully true, is proven 
by examples such as have been alluded to. Thnt constitutional 
causes have, however, quite as much to do with the development 
of caries as have local injuries, is made sufficiently evident in the 
immunity of the numberless persons who have been brought, with- 
out ill result, under the influences of similar local sources of 
irritation. 

It has been suggested that caries may exhibit itself in various 
ways. Yet, however and whatever the manifestation, an ostitis — 
chronic or acute — must precede the ulceration. About the jaws the 
great majority of cases have, in their incipiency, nothing to clistin- 






CARIES OF THE MAXILLJS. 557 

guish them from ordinary periodontitis ; and it is by far most 
frequently the case that the acute attack has been long past before 
this peculiar ulceration is developed, it seeming to be that the resist- 
ive power of the bone is gradually worn out by the presence of 
chronicity ; the inflamed tooth has died, and its devitalization is the 
source of offense. Nearly every case of caries of the jaws that I 
have seen could have been aborted by the timely removal of a certain 
tooth or teeth, — not, of course, all, but that great majority which 
have had dental irritation as the exciting cause. 

A carious bone presents clinical peculiarities according to the 
duration of the disease and the several phases of the causes inducing 
it. If seen early, there is to be observed simply the increased 
vascularity and congestion of the inflammation. A little later, and 
a cacoplastic exudate occupies the cells, which cells, in their turn, 
have become enlarged, and their walls decalcified ; these, still later, 
commence gradually to break down, together with the semi-organized 
lymph exuded into them ; in proportion as such exudation has been, 
and is, extensive, and the breaking down is rapid, the caries may 
be said to be dry or moist Such exudation and degeneration are 
markedly exhibited in many cases of hip disease, or white swelling 
of the knee-joint, where the discharge may amount to quite as much 
as a pint a day. Upon now looking at the bone, we find it riddled with 
irregular cavities, many or all of which are lined by a sort of imper- 
fect secretory surface, or perhaps it would be more correct to say, a 
glazing of semi-organized exudate corpuscles.* If the disease is to 

* "The whole essence of caries consists in this : the bone breaks up in its 
territories, the individual corpuscles undergo new developmental changes 
(granulation and suppuration), and remnants composed of the oldest basis- 
substance remain in the form of small, thin shreds in the midst of the soft 
substance. In ossification (in cartilage) there is a portion of the original 
intercellular substance of the cartilage-cells (secondary cells) which, though 
it belongs to the group as a whole, yet when these, in the course of ossifica- 
tion, are transformed into a number of isolated bone-cells, becomes, compara- 
tively speaking, almost entirely independent of those cells individually (which 
have their own immediate intercellular substance to attend to, and from most 
of which it must be separated by a considerable interval), and therefore 
escapes the changes which befall them. It is this portion which remains 
behind in caries, while the secondary intercellular substance perishes. In 
other processes, however, which run a more chronic course (in cancer, for 
example), everything is destroyed. 

" At the moment a periosteal tissue quits the surface of a bone, and the vessels 
are drawn out from the cortex in inflammatory condition, we see, not as in normal 



558 ORAL DISEASES AND SURGERY. 

involve the whole bone, such will be its general condition. If, how- 
ever, there reside in the part the vital force capable of resisting the 
disease, then from the central point of the disease outward will be 
observed a change in the character of the lymph exuded. The 
farther we get from the centre, the more bland and healthy is the 
exudate ; while the complete filling up of the cells (structural con- 
solidation) exhibits the wall of protection present in circumscribed 
healthy inflammation of the soft parts. It is to be observed, how- 
ever, that this protecting wall is most apt to give way before the 
advance of the disease, — seeming to retard but not to check it. In 
other words, nature seems seldom able, unassisted, to complete a 
line of demarkation, as witnessed in necrosis. 

bone, mere threads, but little plugs, thicker masses of substance ; and if they have 
been entirely drawn out, there remains a disproportionately large hole, much 
more extensive than it would be under normal circumstances. On examin- 
ing one of these plugs, you will find that around the vessel a certain quantity 
of soft tissue lies, the cellular elements of which are in a state of fatty degen- 
eration. At the spot where the vessel has been drawn out the surface does 
not appear even, as in normal bone, but rough and porous, and when placed 
under the microscope, you remark those excavations, those peculiar holes, 
which correspond to the liquefying bone-territories. If it be asked, therefore, 
in what way bone becomes porous in the early stage of caries, it may be said 
that the porosity is certainly not due to the formation of exudations, seeing 
that for these there is no room, inasmuch as the vessels within the medullary 
canals are in immediate contact with the osseous tissue. On the contrary, the 
substance of the bone in the cellular territories liquefies, vacuities form, which 
are first filled with a soft substance, composed of a slightly streaky connective 
tissue with fattily degenerated cells. If round about a medullary canal the 
territory of one bone-corpuscle after another liquefies, you will, after a time, 
find the canal bounded on all sides by a lacunar structure. In the middle of 
it, the vessel conveying the blood still remains, but the substance around 
about it is not bone or exudation, but degenerate tissue. The whole process 
is a degenerative ostitis, in which the osseous tissue changes its structure, 
loses its chemical and morphological characters, and so becomes a soft tissue 
which no longer contains lime. The tissue which fills the resulting vacuity 
in the bone may vary extremely according to circumstances, consisting in 
one case of a fattily degenerating and disintegrating substance (the bone-cor- 
puscles perishing), and in another of a substance rich in cells, and containing 
numerous young cells ; this latter is formed by the division and proliferation 
of the bone-corpuscles, and the newly-produced substance is very analogous 
to marrow. Under certain circumstances this substance may grow to such 
an extent that — if we may again borrow our illustration from the surface of 
the bone where a vessel sinks in — the young medullary matter sprouts out 
by the side of the vessel, and appears as a little knob filling one of the pits in 
the surface. This we call granulation." — Yirchow. 



T& • u be done ia the?e caae> 

Scott. - a MM 

plea: eathar: 

coauti r ii il -racuoa of 

hlaid. aar or ■ ~itk»a. the 
ucntitinorr U 

a tooth id3a: • ■ caase of tb- 



or it bit br in i naaaaaaatioaw it will be 

floaad nfctr:- 
bfiater to the beck o 

saeh a rour- ibeo three or 

- ttned pert, 
-<iu-.nL- a napkin Ua<rk f the 



atoddle of : *ttcteed, 

aad the pa 

a* the acute ear 

ca«*^. wnv::.- . *: 
iron. quin:a 

a had (--■•-:. - • :. the 

acute anion : ■ • \ -teace of 

tstate, the hoot t.. COD- 
nS, 

the tincture of iodic* xnpoonu am, 

ami chloridV 

> the ct 
- far e a ce ni the i •-. .* -o alone 

that a cure b coil: ^-ems 

unable to throw and the 

rare indeed « operative amea fooad 

e means, ho< 
profit to a case, dilv .ered.* 



rtt: - > iaooat iadkauon. 

•TTEpoai* .: ■ -- - t>^~:. B *::-:-. - ariB : :.: ■ : ■: 

tethearraatof ti - ■- ar.i cocsti: 

ahaeeas or ulcer ocev- -ill be oar object to often 

• * j ia order to preTex: i _ 

TTher n:er- <.-..«- naands oc* tfcall treal 

yet w< flaaaaaal ry pr er e? tBe 

Baa -ariri nauahs : - 



560 ORAL DISEASES AND SURGERY. 

To operate for caries of the jaws one seldom requires more than 
two or three delicately-curved chisels, a scalpel, syringe, and an 

ing exhaustion of the system, and still more the poisoning of it by excess of 
mercurial and other active antiphlogistics ; careful not to induce a state 
favorable to the occurrence of destruction in bone. And seeing that caries 
is usually so much connected with taint of system, our attention will be 
directed throughout toward constitutional care in connection with both pre- 
vention and cure. 

"When caries has occurred, the indications of local treatment are abun- 
dantly simple. We are to take away the two portions which are incapable 
of healthy effect, — the interstitially absorbed as well as the truly ulcerous ; 
leaving a solid foundation of normal texture, not only capable of, but already 
engaged in, the business of efficient repair. Afterward, the part is to be 
treated as a simple ulcer ; our anxious care being directed to speedy yet 
efficient and certain closure, lest renewed degeneration supervene; not rest- 
ing satisfied with a blue, elevated, soft, and spongy cicatrix, but insisting on 
the establishment of one which is firm, white, depressed, — plainly incorpo- 
rated with the bone. 

" For effecting the removal, cutting instruments are infinitely preferable to 
escharotics, in all situations where excision is practicable. But as a general 
rule, no operation of any kind should be performed on the bone unless the 
adjacent and superimposed soft parts are in a quiet state. They may be 
undergoing the acute inflammatory process ; they may be the seat of acute 
suppuration, of acute ulceration, or of both ; and removal of a portion of 
bone, imbedded in such soft parts, is almost certain not only to prove futile 
as a means of cure, but actually to aggravate and extend disease. The then 
carious portion of bone may be taken away, but ulceration instead of repara- 
tion is certain to ensue ; and by rapid degeneration the carious condition is 
renewed; or a more general and intense ostitis is kindled, and the partial 
caries is merged in general necrosis. And even supposing none of these 
untoward events to occur, still the time of operation were inexpedient, as 
causing an unnecessary and therefore unwarrantable amount of secondary 
inflammation. 

" The soft parts being already quiet, or having become so under suitable 
treatment, free incision is made through them, so as effectually to expose the 
diseased portion of bone, — previously tolerably well explored by judicious 
use of the probe. The extent of the doomed parts having been satisfactorily 
ascertained, their thorough removal is then to be accomplished. 

" Escharotics in some cases are employed ; as, for example, when a patient 
resolutely objects to any other mode of removal. Or when cutting instru- 
ments have been used, and yet a border of suspicious character remains, the 
extinction of such a suspected part may sometimes be conveniently enough 
intrusted to cauterization. The actual cautery may be applied, but unwisely. 
It effects too much. The carious part is at once and satisfactorily killed ; but, 
as in all severe burns, the texture immediately surrounding the eschar, 
though escaping with life, has its vitality very much impaired, and is more 



CARIES OF THE MAXILLAE. 561 

acidulated water. Taking the fistula for the guide, the bone is ex- 
posed by a simple incision. Next, with a chisel, suitable in size, 
the softened structure is, little by little, cut away. 

The extent to which caries will occasionally be found to have 
progressed is a matter of surprise. One can do no better, how- 
ever, than follow the softened bone, wherever it may lead. I have 
very frequently, in this way, been led from an apparent simple be- 
ginning, to remove nearly or quite all of the upper jaw. Danger 
from hemorrhage has not been, in my experience, any special occa- 
sion of anxiety ; indeed, I fail to recall a case in which the injection 
of alum-water has not been all-sufficient for its control. When 
healthy bone is reached in an operation, it is distinguished from the 
carious both by the touch and sight. Under the gouge the first is 
hard and springy, the latter soft and brittle. Passing, with the* in- 
strument, from the diseased to healthy tissue, one could not fail to 
remark a difference. To the sight, healthy bone is white and vas- 
cular ; carious bone is dark and non-vascular, or it is a deadish white, 
or oleaginous. A very observable difference between caries and 
necrosis consists in the absence, in the former, of the odor associ- 
ated with the latter, caries running its whole course without neces- 
sarily giving the slightest annoyance from this cause ; at least, 
where proper cleanliness has been observed. 

The use of the syringe, after an operation for caries, is of the 
greatest moment; the capacity should not be of less than one gill, 
and every particle of detritus is to be carefully washed away. In the 
after-treatment, this instrument will also be found to perform good 
service, — repeated washings with the proper medicaments being 
very conducive to a cure. 

The use of sulphuric acid in the treatment of caries, designed to 
unite with the base of the phosphatic salts of the bone, and thus 
remove it, introduced into practice by George Pollock, F.R.C.S., 
surgeon to St. George's Hospital, has justly attracted much atten- 
tion. Used in that state, in which nature, possessed of the requisite 
resistive force, has compelled the line of demarkation, and needs 
only the assistance of relief from the dead tissue, sulphuric acid 



prone to disintegration than to repair. The potential cautery is infinitely 
preferable. It destroys the diseased part just as effectually, though, perhaps, 
with less rapidity, and at the same time the immediately adjoining parts do 
not in any wise suffer, but at once institute a healthful line of demarkation 
for removal of the dead part, and are well able to commence, at the same 
time, a sthenic action of repair." — Miller. 

36 



562 ORAL DISEASES AND SURGERY. 

employed in a required strength will undoubtedly dissolve such 
dead bone and thus allow a cure. Again, used as a local stimulant, 
it exerts most excellent influence, exciting into action, and seeming 
to afford support to all the abeyant force of the parts. Still again, 
used as an antiseptic, its effects are very beneficial, assisting in keep- 
ing the parts fresh and clean. 

In using sulphuric acid with a view to the solution of dead 
bone, one part of the officinal may be diluted with eight of water ; 
or, if preferred, the aromatic acid may be used either pure or diluted. 
Mr. Pollock himself uses the acid, at first diluted with equal parts 
of water, and then more and more nearly pure, penciling the surface 
which he exposes by turning aside the soft parts. When the acid 
is employed simply as a stimulant or antiseptic, the circumstances 
of each case will govern the strength of the application. 

The employment of caustic potash for destroying quickly disin- 
tegrating bone has the recommendation of no less eminent authority 
than Dr. Fitzgerald, of Dublin. When tested, however, by the side of 
sulphuric acid, it is to be agreed that there is no comparison. With 
the former agent, secondary injuries may associate ; with the latter, 
nothing but good is to be anticipated.* 

* "Acid does not affect or injure the soft tissues when used in the diluted 
form : acting chemically on the diseased bone alone, it does not affect the 
living bone, and its application is seldom followed by any great degree of 
pain. 

" That, in the diluted form, it will only act on dead or diseased bone, and 
not on healthy bone, is a point of very considerable practical importance, 
and is the great advantage sulphuric acid possesses as an application, under 
the circumstances quoted, over the use of the gouge, or of the actual cautery, 
or of caustic potash. The following experiments, conducted at my request by 
Mr. Henry M. Noad, lately my clinical clerk-, satisfactorily prove the cor- 
rectness of this statement. 

" Portions of dead, diseased, and healthy bone were selected and subjected 
to the action of sulphuric acid, viz. : 

" 1. Dead bone, 10 grains. 
" 2. Diseased bone, 10 grains. 
" 3. Healthy bone, middle age, 10 grains. 
" 4. Healthy bone, old age, 10 grains. 
Exposed to the action of a mixture of sulphuric acid and water, one part in 
four, for three days, at a temperature of 100°, the following were the results: 
"1. Dead bone: Phosphate of lime, 2 gr. ; carbonate of lime, 3.30 gr. ; 

dissolved in the mixture. 
" 2. Diseased bone : Phosphate of lime, 2 gr. ; carbonate of lime, 1.3 gr. ; 
dissolved in the mixture. 



CARIES OF THE MAXILLJE. 563 

Illustrations in Practice. — Mary B , girl of weakly constitu- 
tion, with caries of inferior maxilla involving the body of the bone 
from the second bicuspis of one side to the first molar of the other, 
the teeth being in place, but very loose, three sinuses existing in the 
gum overlying the disease, which sinuses were in constant discharge. 
Examination with a sharp-pointed steel probe exhibited the bone as 
so honeycomb-like that the instrument could be pushed through the 
parts without difficulty. 

Treatment and Result. — Patient kept on a chalybeate tonic for 
three weeks, then operated upon before hospital class. Desirous of 
testing the reparative powers, a cut, uniting several sinuses, was 
made below the apices of the roots of the teeth, and with delicate 
gouges the softened bone was scraped away, allowing the teeth to 
remain supported almost exclusively by the gum. After the opera- 
tion, the parts suppurated from the superficies of the bone more or 
less for three months, the left cuspis being thrown off by a slough 
of the immediately overlying gum. At the end of this period, an 
osteophytic sequestrum was exfoliated, after which the wound 
closed, the teeth gradually became firm, and a cure, with the teeth 
preserved, was happily secured. Locally, sulphuric acid alternated 
with the chloride of zinc was used. Systemically, advantage was 
endeavored to be taken of all tonic influences : exercise in the open 
air, and sunshine, salt-water sheet-baths, juicy undercooked meat, 
the compound tincture of gentian as an appetizer, etc. 

The use of sulphuric acid in caries, acting to the chemical de- 
composition of bone, may readily be conceived as possessed of much 
good import ; indeed, it may very well be recognized as possessed 
in itself of power sufficient to a cure, doing chemically that which 
the gouge does mechanically. The strength in which an acid is to 
be used depends entirely upon the effect desired to be accomplished. 

" 3 and 4. In both specimens of healthy bone, no action took place. 

" The process of disintegration or dissolution, with the commencement of 
healthy granulation from the surface of the living bone, may be observed 
simultaneously progressing, in any exposed surface of dead or dying bone to 
which the acid may have been applied. "When its action and effects are com- 
pared with those of the gouge, the bruising which is necessarily produced by 
the use of the latter, the pain and frequent subsequent inflammation, and, 
even under the most favorable circumstances, the time required for the rough 
lacerated surface to recover itself, throw off its small bruised fragments, and 
become covered with granulations, the treatment by sulphuric acid will be 
found far preferable." — Pollock. 



564 ORAL DISEASES AND SURGERY. 

If employed with the anticipation of decomposing the affected bone, 
the undiluted aromatic sulphuric will scarcely be found over-strong. 
Personally I have frequently made test of such strength, and even 
much stronger, using, indeed, the pure officinal ordinary sulphuric 
acid, taking, however, the precaution to make direct applications 
with a stick brush. Where the acid is used merely as a stimulant, 
the aromatic is to be diluted pro re nata. 

Case II. — French lady, about twenty-three years of age ; caries 
of base of alveolus of right cuspis of superior jaw, involving the 
palatine process, with discharge beneath the covering of the hard 
palate ; two tumors, one the size of a hickory-nut, the other that of 
a hazel-nut, existing. 

Treatment. — First opened the sacs, giving vent to the accumu- 
lated pus, the bone being found denuded quite the size of a dime- 
piece. Once each day, for the period of two weeks, the sacs were 
injected with sulphuric acid and water, one part of the first to twelve 
of the second. At the end of this time the cure was complete, 
granulations after the sixth day being recognized as covering the 
exposed bone. 

In this second case, close observation elicited the fact that the 
acid acted just as any other stimulant would have done. Iodine 
or zinc might have been used with a precisely similar result, — power 
existing in the natural force of the patient to overcome the destruc- 
tive condition, requiring only the aid of slight stimulation. 

Case III. — Merchant from isew York City ; caries of both palate- 
plates of superior maxillae. In this case, while two sinuses existed, 
the mucous envelope of the hard palate was found separated from 
its bony base, forming a tumor which half filled up the mouth. Ex- 
amination revealed the palatine processes riddled with holes. This 
was a character of case most admirably suited to acid treatment, 
and which was recommended. A diagnosis of different character 
afterward offered in another city resulted, however, in resection of 
the bones ; an operation as unnecessary as the diagnosis was faulty, 
and from which operation the author is under the impression the 
patient died. 

Case IY. — A very delicate lady, about twenty years of age ; 
caries arising from presence of a lateral incisor tooth containing a 
dead pulp. When this patient first presented herself, no external 
evidence of disease existed, except that implying chronic inflamma- 



CARIES OF THE MAXILLA. 565 

tion of the membrane surrounding the root of the tooth, the organ 
being loose, slightly elongated, and sore ; the gum, however, over the 
apex of the root was healthy-looking. Treatment directed to the cure 
was commenced by drilling an opening into the pulp chamber, through 
the palatine face of the tooth ; the cavity entered, a discharge of 
pus was the result. A succeeding step was an exploration of the 
parts about the apex of the root, effected by passing a sharp steel 
probe through the soft parts. This, meeting bone, was thrust for- 
ward, revealing a cavity the size of a hazel-nut, the parietesof which 
were found spongy and soft. This cause, condition, and character of 
caries are those most frequently met with in the upper jaw. Treat- 
ment of the case, which resulted in a cure in ten days, was as 
follows : 

The pulp chamber was thoroughly washed out with water medi- 
cated with creasote. The length and circumference of the pulp 
canal were measured, and a delicate pyramidal cylinder of gold 
was passed and consolidated to the apex. This manipulation was 
not, however, a necessity, but had reference to the preservation of 
the future usefulness and color of the tooth. This accomplished, 
the parietes of £he carious cyst were well broken up by means of a 
sharp excavator, and the detritus removed through the aid of the 
syringe. Injections of sulphuric acid and water, one part of the first to 
eight of the second, were now used for ten successive mornings, 
when the cyst was found filled with organizable material, and the 
cure remained complete. 



CHAPTER XXVIII. 



NECROSIS. 

Directing attention to the foot-notes, as embracing a diversi- 
fied discussion of the condition and character of necrosis, the text 
of the chapter will present the subject in its clinical aspect.* 

Necrosis, signifying death of bone, while common to both the supe- 
rior and the inferior maxilla, exhibits decided preference for the 
latter, attacking it, as the author would be led to infer from the ex- 
perience of his own practice, in twenty cases to five of the former. 
The disease presents a twofold primary expression. It may com- 
mence as a general ostitis : stasis of the circulation quickly antag- 
■ » 

* "As soon as that peculiar mutual dependence and reciprocation of parts 
has ceased in the human body, which emanates fromiheir genetic unity, and 
which we call life, it encounters the same conditions of the outer world as do 
the inorganic bodies : that is to say, the only force which tends to maintain 
it in its form is cohesion. This, however, owing to the extraordinary abun- 
dance of water, is very limited, and hence immediately after the occurrence 
of death the decay of the body begins, which takes place at first slowly, then, 
however, continually more and more rapidly, and finally leads to its complete 
dissolution. As long, moreover, as the outer form is in any measure retained, 
we call the body dead, understanding by this term that a body, although still 
exhibiting organic structure, is no longer the seat of organic function. 

"At the death of the entire organism, medical skill, as it is known, ceases. 
"We might, therefore, spare ourselves the trouble of studying the changes 
which the death of the tissues occasions, were there not also a partial death, 
or death of individual parts of the organism, which we call necrosis, morti- 
fication, gangrene. 

" The anatomical changes which follow the occurrence of partial death are 
not the same in every case. The very various causes producing necrosis, as 
well as the natural situation and constitution of the dead parts, condition 
widely-separated varieties, especially as to the amount of blood and water 
contained, which give occasion to the production of a dry or a moist gan- 
grene." 

For a series of the most widely-suggestive and practical annotations bear- 
ing upon the general subject of necrosis, the reader is directed to Professor 
Kindfieisch's Text-Book of Pathological Histology, pages 21 to 70. 
(566) 



NECROSIS. 567 

onizing nutrition, thus killing the bone outright ; or, as more com- 
monl} r witnessed, it is a result of periosteal disease, the membrane 
affected being the periosteum proper, or, as recognized in a great 
majority of instances in which the condition is met with, the al veolo- 
dental tissue, — periodonteum. In such primary membraneous as- 
sociations, either the tissue, as it reacts upon the bone life, is 
found dead, or it is seen separated from the bone by a degener- 
ating plastic exudate.* In such inflammations and separations, 
it would be inferred that the layer of bone immediately adjacent 
to the membrane would be the first to be affected ; this is so truly 
the case that timely incisions and combating of the inflammation are 
most influential in the limitation of the disease, — this being most 
markedly exhibited in periodonteal inflammation. The superior 
jaw, however, is much more liable to take on a general inflammation 
than the inferior; but the higher vascularity and resistive force of 
this part seem to enable it to resist the destructive action and to 
limit the part overwhelmed. 

Inflammation of the jaws, whether osteal or periosteal, is pri- 
marily to be treated on general principles. If acute in character, we 
may first try the effect of the hot pediluvia and saline cathartics. 
These failing, the parts may be well scarified, or leeches may be 
applied, or blood taken from the arm. Diaphoresis may be employed. 
In short, antiphlogistics of any and every nature, promising con- 
trol of the excitement, maybe pressed into service. If all, however, 
fail, and pus forms, vent cannot too soon be given it. When, on the 
contrary, an inflammation is chronic and asthenic in character, as 
marked in the puffy, debased character of the parts exhibited in the 
dyscrasic, with the necessity for free scarification will exist a demand 
for local stimulating douches and the administration of tonics. Of 
the supporting medicines applicable to these cases, the very best, 
I think, will be found in the union of sulphate of quinia with the 
muriated tincture of iron. A combination very frequently employed 
is as follows : 

B. — Tincturse ferri chloridi, §j ; 
Quinias sulphatis, 3j. M. 
Sig. — 15 drops in water four times a day for an adult. 

* In necrosis confined to part of a bone, the increase in the vascularity of 
the parts, as shown by the curious cases exhibited by Mr. Paget, — see his lec- 
tures on Nutrition, — may give rise, especially in young persons, to hyper- 
trophy of the remainder. 



568 ORAL DISEASES AND SURGERY. 

Ostitis, as a primary expression, exhibits its most intractable cases 
in the periods connected with dentition, whether first or second; the 
irritability being increased and kept up by the excitability associated 
with this process. Hence the great amount of care necessary to 
guard against any increase in the vascularity natural to such age. 
The trouble aroused, nothing can be done, however, beyond such 
treatment as applies to ordinary cases ; except, indeed, it will be 
found that there exists a greater necessity for the use of sedative 
medicaments. 

In directing treatment to a condition of ostitis or periostitis, as 
relation is had with necrosis, an indication of principal signification 
lies in the discovery, and removal when possible, of the exciting 
cause or causes. That such causes may have proper and definite 
signification, we proceed to the division and study of the subject as 
clinically it presents its diversified phases and aspects. 

In the order of frequency in which maxillary necrosis is met with, 
the following table may be accepted and studied : 

1. Dental necrosis. 

2. Alveolar necrosis. 

3. From lack of room for eruption of wisdom-tooth. 

4. Syphilitic necrosis. 

5. Mercurial necrosis. 

6. Necrosis from injuries.* 

7. Exanthematous necrosis. 

8. Phosphor-necrosis. 



* "The complete cessation of nutrition within a certain mostly circum- 
scribed portion of bone is followed by a series of inflammatory processes in 
the neighborhood, whose final result is the loosening and separation of the 
dead from the living parts. The course of these changes is mostly determined 
by the particular cause of the necrosis. In traumatic necrosis, under certain 
circumstances, the loosening of the dead portion from the living is already 
effected (comminuted fracture), but the concealed situation makes a rapid 
extrusion impossible for the time being. In injuries, also, a purulent peri- 
ostitis is mostly the force bringing about the necrosis, as it is present, as the 
first and only cause, in by far the most cases of necrosis. The purulent peri- 
ostitis culminates, as has been mentioned, in a collection of pus between the 
periosteum and bone. A preformed cavity, capable of dilatation, does not 
exist here, but probably the cambian layer of bone (M. Schultze), especially 
in youthful, still-growing bones, is so soft that comparatively slight resistance 
is offered to its loosening. Only the vessels which pass tolerably numerous 
from the periosteum to the cortex of the bone, must be ruptured, and it 



NECROSIS. 569 

Dental Necrosis. — Dental necrosis — death of the teeth — may 
claim a first attention as being the most common of all the troubles 
of the ossa corporis. 

depends on the intensity of the inflammation — that is, on the quantity of the 
pus — to what extent this is accomplished. This laceration of the vessels is not 
incorrectly looked upon as a principal cause of the frequency of peripheral 
necrosis after purulent periostitis. It is, in fact, very obvious to designate 
the direct interruption of the supply of blood to the outer third of the com- 
pact substance, which properly belongs to the periosteum, as the cause of the 
complete cessation of vital processes in just this third. Nevertheless, although 
necrosis does not follow upon purulent periostitis by any means in all cases, this 
must not determine us to reject, without more ado, this so evident etiological 
agent, but invite us to seek the causes of the exception in peculiar relations ; 
for example, in a substitution, still possible, at the right time, of the cortical 
circulation of the vessels of the medulla. Only the pus itself is to be regarded 
from the beginning as something excreted from the organic unity, in this 
sense dead. Its presence excites a sequestering inflammation, as well in the 
periosteum as in the bone. The periosteum is very soon converted into a 
pyogenic membrane, which protects and excludes the organism against its 
own secretory products. In the bone there develops a rarefying ostitis, whose 
office it is to exclude the organisms from this side also by a layer of granulation 
tissue from the dead part. This rarefying ostitis is nourished from the medulla, 
and reaches as far into the compact substance as its vascular tracks have re- 
mained open and in circulation. There are cases where it develops upon the 
upper surface, when the Haversian canals dilate and the tissue of granulation 
springs up in numberless vascular villosities and unites into a continuous layer, 
which then connects with the elevated periosteum into an abscess membrane 
inclosed all around. More frequently, it is true, the outer layers of the com- 
pact substance have been too long deprived of circulation and the exchange 
of material for their revitalization to be possible by the medulla, and their 
own rarefying ostitis appears as a sequestering inflammation, which separates 
the lamellae that have perished, and ends in pus, which fills the abscess cavity. 
The dead bone is called sequestrum ; the rarefying ostitis which separates it, 
demarkation. The demarkation may occupy months and years. During this 
time the suppuration continues uninterruptedly ; the elevated periosteum, 
however, again returns to its ossifying capacity, and forms under the pyogenic 
surface a layer of new osseous tissue, which in time may attain a very con- 
siderable thickness. A bony capsule, called cofiin (Todtenlade), which is thus 
produced, lodges the more or less loosened sequestrum in its interior. The 
adjacent, not elevated, periosteum, also participates by ossifying periostitis. 
For a distance upward and downward osteophytes and exostosis arise in vary- 
ing form and number. All these phenomena of inflammation, extending to 
some distance, disappear as soon as the sequestrum is successfully removed. 
Even the bony capsule diminishes, and by the obliteration of the cavity of 
the abscess it again applies to the surface of the bone, the exostosis disappears, 
and the bone again assumes its normal form." — Rindfleisch. 



570 ORAL DISEASES AND SURGERY. 

A tooth has a twofold source of vitality, — an internal or tubular 
circulation, secured from its pulp ; and an external or membranous. 
The destruction of this internal circulation, through the killing of 
the pulp and filling the root-canal with metal, is so common an 
occurrence as to be familiar to almost every one. 

By the majority of teeth, if properly treated, such destruction 
seems to be sustained without much apparent inconvenience. This 
treatment consists, as we have learned, in extracting from the cavity 
every particle of the dead pulp, and so filling the chamber with gold 
or other material as to prevent the introduction of more irritating 
matter. Where teeth, however, are not properly treated, or where 
there is great susceptibility in the system- to inflammatory action, 
the destruction of the pulp results in an extension of the destructive 
action to the periodonteal membrane, yielding the trouble known 
as periodontitis ; this, if not aborted or resolved, terminates in the 
death of the tooth. 

A dead tooth is not, however, fortunately, treated in all cases by 
the system, or even in the majority of cases, in so summary a man- 
ner as a piece of dead bone. As a rule, there exists a wonderful 
forbearance on the part of nature to its presence, and the organ 
may be retained in its cavity and made to serve useful purpose for 
a long time. True, it is discolored, and, provided there is no 
decomposing pulp in the canal, in proportion to this discoloration 
may the degree of death — if I may so speak — be judged. A tooth 
lowers in the scale of vitality in various degrees. It may be dete- 
riorated as the death of part of its pulp is concerned, or as the death 
of all of it is implied, — as regards the whole or any part of its en- 
veloping membrane. When both pulp and membrane are dead, the 
tooth, of necessity, must be dead with them ; and in proportion to 
their destruction, so is its destruction. 

Some systems are so irritable that all skill might not make the 
mouth retain a tooth in which simply the pulp is dead. Others, on 
the contrary, are so unimpressible that half the teeth in the arch 
might be utterly necrosed, and yet no complaint be made. The author 
once, as an experiment, replaced in the mouth a central incisor tooth 
which had been extracted twelve hours before, and although it had 
been carried in the pocket, enveloped in the usual collection of dust, 
tobacco, keys, knife, etc., the whole intervening time, it was kept in 
its socket until the parts became reconciled. Many years have since 
passed, and it seemed, when last seen, about as useful as in its 
palmiest days. The repetition of this experiment is now common. 



NECROSIS. 571 

The irritation, inflammation, and death of a tooth are generally 
the result of caries exposing its pulp. The first stage in the destruc- 
tive process is the death of this part ;* here it may end, the pulp 
sloughing off at the foramen, and the periodonteum assuming the 
full duties of nutrition. If this is not the case, this membrane be- 
comes involved; if it too should die, the root is left as if scraped : 
the tooth is then dead. A dead or partly dead tooth is recognized 
by its loss of translucency, the opacity varying from the slightest 
discoloration to complete blackness. 

A dead tooth is not, however, necessarily associated with caries. 
Inflammation, resulting in its destruction, may be induced by at- 
mospheric changes, blows, etc. This should be recognized, so that 
by reason of the absence of decay a diagnosis may not be obscured. 

A dead tooth is thrown off in two ways : either by chronic or 
acute action. When by acute means, violent inflammation is 
set up in all the surrounding parts, the tooth is elongated and 
loosened, much pus is discharged, and eventually the tooth drops 
from its socket ; this accomplished, the trouble commonly subsides. 
In chronic exfoliation, the parts indurate, one or more sinuses form 
as in ordinary abscess, all the parts about the tooth are thickened 
and rough, as if some ugly disease was in process of development, 
and the tooth generally grows dark, perhaps black. It does not get 
loose, but is apt to frighten into its removal. If such extraction be 
not resorted to, the disease involves the bone, and tooth and alveolus 
become eventually cast off as a common sequestrum. Another, and 
more common chronic form, consists in the gradual absorption from 
about the roots of a dead tooth of its alveolar process. This is 
most common to old persons, although not by any means so con- 
fined. This form of exfoliation is usually very slow in its progress, 
extending over a period sometimes of several years. Cases, how- 
ever, frequently present — confined to young persons — where several 
teeth are cast off in this manner within eight or nine months. 

Teeth sometimes die as the result of general structural consolida- 
tion. This never occurs but in what are commonly recognized as 
very dense teeth, and is seldom found associated with caries. Such 
teeth . loosen day by day, and finally — it may be after a period of 
years — drop from their cavities. The condition is seen alone in old 
persons, or in those beyond middle age. To arrest this trouble 

* The pulp of a tooth is composed of most delicate connective tissue, in 
which ramify the vessels and nerve. (See diagram.) 



572 ORAL DISEASES AND SURGERY. 

seems impossible. I know of no treatment that has ever seemed to 
have the least effect. 

Alveolar Necrosis. — The membrane enveloping the root of a 
tooth is associated, as a nutritional vehicle, with its alveolus ; hence 
it is commonly termed the " alveolo-dental periosteum." As the 
result of such relationship of structure, an inflammation originating 
in a tooth extends to the surrounding bone, and, according to its 
severity, affects the parts involved ; hence portions of alveolus, 
overwhelmed, as it were, by the force of the attack, sometimes die 
and sequester. This form of necrosis, while very common, would 
perhaps with proper treatment seldom occur. 

The dentist, for the purpose of destroying the pulps of teeth, 
applies the arsenical mixture. This is placed in a cavity of decay, 
and covered with cotton or wax. It happens, however, occasion- 
ally, that from an improper application, or some difficulty of retain- 
ing it in place, the paste oozes down around the neck of the tooth, 
and thus acts upon parts not intended in its application, inflaming 
them. In this way alveolar necrosis is sometimes induced ; the 
portion destroyed is seldom, however, very considerable, and gen- 
erally exfoliates in from two to four weeks. The local application 
of the sesquioxide of iron has been thought by some to exert a happy 
effect, applied immediately on the discovery of the accident. Re- 
peated syringings are not to be neglected. A case, occurring in the 
person of a physician, has, at this date of writing, been treated by 
the author, where arsenic had been sealed in a tooth-canal having a 
drill-hole through it communicating with the alveolus. As a result, 
all the bone forming the envelope of the antrum was destroyed and 
came away. 

Alveolar necrosis is sometimes induced by the application of 
chloride of zinc, used as an obtunder of dentinal sensibility, and also 
for the purpose of controlling the slight hemorrhages caused by the 
slipping of instruments in the operation of filling. The first effect 
is of course upon the gum, inflaming and engorging it, the effect 
upon the bone being secondary. Nothing better than the ordinary 
antiphlogistic applications can be employed. The action here is 
much more tardy than in the destruction induced by arsenic ; the 
sequestrum, however, is seldom very considerable, the alveolus per- 
haps of a single tooth. The action of nature in the separation should 
always be awaited. 

Cases which, for want of a better name, might be termed anom- 
alous, sometimes occur. A single instance may illustrate. I. B., an 



NECROSIS. 573 

Irish laborer, consulted for pain in the two inferior incisor teeth. 
No caries, no periosteal inflammation, nothing indicating disease, 
was observable. The pain increased day by day, until at the end 
of the second week the two teeth and their alveoli were found 
detached, and were dissected from the gum. This case is one of a 
very few of the kind that have been met with, and which may well 
be termed anomalies. The pulps are not found dead if examined at 
such time, as under ordinaiy circumstances one would expect to find 
them. There is no soreness of the teeth on pressure, and, strangest 
of all, there are none of the common phenomena of inflammation. 
The practitioner in these cases must be guided by such indications 
as he may be able to seize upon. The condition is, in every sense 
of the word, strange. 

Necrosis from Lack of Room for Eruption of Wisdom-Tooth. 
— This is found most commonly associated with the lower jaw. The 
close relationship of the second molar with the ramus frequently 
makes the egress of the advancing wisdom-tooth an impossibility ; 
hence an irritation resulting in inflammation. The serious extension 
of the trouble to the bone is always, however, preceded by more or 
less trismus and difficulty in deglutition: thus every chance is given 
for an anticipating surgical relief. This form of necrosis is to be 
looked for between the seventeenth and twenty-fifth years. The 
extraction of the second molar allows the wisdom-tooth to fall for- 
ward ; thus the irritation is removed and a cure effected. These 
cases are, if rightly treated, as simple and harmless as they are 
severe and prostrating if left to chance or improperly managed. 
Extract the second molar tooth, and do not attempt the removal of 
the offending one, — that is, if such extraction threatens difficulty.* 

* " The advent of the wisdom-teeth is very often accompanied by painful and 
distressing symptoms, that may be protracted through many months, or it 
may be even years, unless relieved by surgical interference. These circum- 
stances arise from the position occupied by the wisdom-teeth, so close to the 
joint of the lower jaw, where the mucous membrane is reflected from the gum 
to the cheek and fauces, combined with the very common condition that the 
jaw is not sufficiently elongated backward to allow the dentes sapientise to 
range in the horizontal series with the other teeth. This mechanical diffi- 
culty not only prevents the proper evolution of the wisdom-teeth, holding 
them back in their bony bed, but it often perverts their direction of growth 
and dislocates them. Annoying and very painful as are often the symptoms 
attendant on difficult cutting and misplacement of the upper wisdom-teeth, 
they are trivial in comparison with those which occur in similar conditions 
of the lower. 



574 ORAL DISEASES AND SURGERY. 

Exfoliations of laniinee of bone are very common after the opera- 
tion of extraction of teeth. Such scales vary in size from that of 
the finger-nail to a pin's head. They seldom require any particular 
attention, coming away generally without pain or trouble of them- 
selves. 

" The ordinary misplacement of the upper wisdom-teeth is either backward 
or outward, or in both directions combined. "When the teeth point back- 
ward, every time the mouth is closed its crown comes in contact with the 
mucous membrane, passing up on the base of the coronoid process. When 
the direction is outward, which is more common, the tooth projects into the 
cheek, and when the jaws are brought together, a portion of the mucous 
membrane in this region is nipped and pinched. This is a very painful 
affair ; the surface becomes ulcerated and extremely tender ; there is partial 
cicatrization, and the structure becomes stiff and hard as well as painful. 

"The difficulty which most commonly occurs with the inferior dens sapi- 
entise is attributable to insufficient room in the jaw. The tooth grows nor- 
mally in direction and in position as regards its neighbor in front, but, from an 
imperfect lengthening of the horizontal ramus of the jaw, the birth of the 
crown is only partial and incomplete. The tooth is upright, but only its front 
cusps emerge, while the hinder cusps are still covered in with gum (see, for 
lesions, page 200), or the wall of the bony loculus in which it was formed. This 
produces a terrible pinching of the mucous membrane every time the jaws 
are brought together. Before, however, the enamel eminences of the tooth's 
crown make their appearance, the soft structures behind the second molar 
become much inflamed, and often suppurate. The inflammation to which 
the impaction and pressure give rise extends to surrounding tissues ; the cheek 
becomes stiff and painful, and deglutition is difficult, and attended with sore- 
throat. 

' ' Next in frequency to the foregoing malposition is that in which the wisdom- 
tooth is developed horizontally forward, more or less. It is attended often 
with serious consequences. This direction is sometimes combined with an 
inward leaning, and very rarely the crown of the tooth points outward. 
This latter dislocation is very unusual, but the most severe case of suffering 
from displacement of the lower wisdom-tooth which I have ever seen was of 
this variety. 

" The most distressing result, however, that occurs in these cases is the 
suppuration which sometimes attends the difficult eruption of the tooth. 
In slight cases, even where there is no misplacement or want of room, but 
simply a restrained progress from an unusually dense or cartilaginous over- 
lying gum, pus will be occasionally formed. In severer cases, the pus bur- 
rows among the areolar tissue, around the periosteum of the jaw ; the neigh- 
boring soft structures become infiltrated with lymph, and the integument is 
glued irregularly to the bone ; pus points, at different spots, often remote from 
its original source; and the whole cheek may be undermined with sinuses." — 
S. James A. Salter — Holmes. 



NECROSIS. 575 

Syphilitic Necrosis. — The hard palate seems particularly liable 
to suffer from attacks of this specific disease, the veuereal ulcer of the 
overlying soft parts and that of the soft palate being observed as 
among the most common of the constitutional affections. That 
these ulcers are, however, strictly venereal, one may be oftentimes 
led to doubt ; certain it is that they appear and exist with greatest 
virulence where mercury has been used with unnecessary freedom. 
Venereal ulcers of the mouth are of two kinds : the superficial, and 
the ordinary ulcer of necrosis ; either of them being represented in 
general appearance by the non-indurated chancre. The superficial 
ulcer may be found both upon the hard and soft palates, but is much 
more common to the latter. These ulcers — as the chancres — vary 
in size and character, being sometimes very amenable to treatment, 
at others resisting and phagedenic, even to the destruction of the 
parts. Their treatment is to be conducted on general principles. 
Few surgical conditions require nicer general judgment or more 
attentive care ; it is, really, to blow hot to-day and cold to-morrow, 
and vice versa. As a rule, such ulcers are oblong in form, from an 
eighth of an inch to an inch or more in length ; more or less exca- 
vated, the cavity being filled with a dirty-white semi-solid paste. 
The truest practical comprehension of these cases is found, as the 
experience of the author leads him to infer, in looking at them as 
one looks at scorbutus. 

Touching locally with the acid nitrate of mercury, with the nitrate 
of silver, or with a mixture of equal parts of iodine and creasote, not 
uufrequently causes them speedily to assume healthy action. A 
case will seldom be met with in which the internal exhibition of a 
mineral acid does not seem to be in some degree useful ; and par- 
ticularly is this found to be the case where a phagedenic tendency 
exists. Whatever remedies, however, be employed, the venereal 
basis of the trouble is always to be kept in mind. Syrup of the 
pyrophosphate of iron, conjoined with minute doses of corrosive 
sublimate and iodide of potassium, will, under certain conditions, 
compel such ulcers to disappear as if by magic; or a combination 
which may be employed commonly with a happy effect is as fol- 
lows : 

R. — Hydrargyri chloridi corrosivi, gr. ij ; 
Potassii iodidi, 5U ; 
Syrupi hypophosphitis, ^iij ; 
Syrupi sarsaparillse composite, ^iij. M. 

Sig. — Tablespoonful three times a day. 



576 ORAL DISEASES AND SURGERY. 

The ulcer of necrosis, looking like the preceding, differs from it 
in having the pasty mass, which constitutes the apparent bottom, 
associated with dead or dying bone beneath. The ulcer in this case 
is not the trouble to be cured, — indeed, could not be cured while the 
underlying disease exists. Ulcers of this class, being an attendant 
condition, are always, of course, situated over the bones, generally 
about the maxillary and palate sutures. They are always preceded 
by an engorged and tumid state of the parts in which they are 
situated, indicative of the osseous trouble beneath. The character 
of this tumidity is a matter of much concern, as in proportion to its 
solidity will generally be found the extent of destruction in the soft 
parts ; the variability of such destruction is seldom, however, in 
proportion to the disease below. The author has seen the whole 
palatine process die while the indicative ulcer has not been larger 
than the eighth of an inch in circumference ; on the contrary, the 
smallest sequestrum will sometimes be found attended with the 
largest ulceration. 

Incision into and through this tumid engorgement will always 
be found satisfactory practice. The cuts, however, are to be made, 
not carelessly, but with judgment ; always taking into consideration 
the vitality of the part. Such incisions, if made through the peri- 
osteum, will frequently be found to exercise quite a controlling influ- 
ence on the ostitis, just as in cases of ordinary inflammation, while 
the effect upon the soft parts is always for good. The treatment 
which should succeed the incisions is only to be determined by the 
circumstances of each particular case; not unfrequently it will be 
found amply sufficient to keep the parts well cleansed, and await the 
coming away of the sequestrum ; never, however, forgetting to meet 
the constitutional indication. In other cases, as when, for example, 
the phagedenic type is assumed, the most vigorous and well-directed 
local treatment is necessitated ; when cases are first seen in the open 
ulcerated condition, semi-indolent, as is frequently the case, no treat- 
ment seems superior to packing the ulcer with cotton saturated with 
creasote and iodine. Cases have come to the writer for treatment 
where the bone would be found exposed to the size of a silver three- 
cent piece, and where all the consequences of a large opening into 
the nares were to be apprehended, yet, by such an application, re- 
peated every other day, allowing the cotton to remain in the ulcer 
the intervening time, in the course of two weeks the denuded bone 
has entirely granulated over, and the parts have remained perma- 
nently cured. 



NECROSIS. 577 

Breaks occurring in the hard palate, associating the oral cavity 
with the nares, are easily remedied by a covering of gold or silver 
plate. An impression of the full roof of the mouth is taken in wax ; 
into this is poured plaster in a cream form ; to the cast thus pro- 
cured is fitted the plate of metal, supported by the teeth, or by 
atmospheric pressure, precisely as in the case of a plate for the 
attachment of teeth. Any reasonably ingenious mechanical dentist 
can meet the indications. (See Obturators.) 

In breaks of the soft palate a simple wad of cotton may be tem- 
porarily used with a considerable degree of satisfaction. Astonishing 
results in the way of diminishing or closing these breaks, both in the 
hard and soft palates, may not unfrequently be secured by freshening 
the edges and touching every second or third day with iodine, zinc, 
dilute sulphuric acid, or the compound tincture of capsicum. Great 
care is, however, to be exercised in this practice not to over-stimulate 
the parts, very troublesome degenerating inflammations being some- 
times the result of an over-excitement. 

An ugly feature in the syphilitic ulcer is its tendency to recur: 
a palate, looking healthy to-day, will assume to-morrow an indo- 
lent relaxed type, becoming semi-yellowish; some point or other 
will take on a fatty look, and in a few hours break down into an 
ulcer. This may recur a dozen times ; the explanation is to be looked 
for in the systemic condition. Such recurrence of the ulceration may 
extend over a period of six or eight months, in defiance of the most 
careful attention. The author has certainly found it so in his own 
practice, and believes it to be a common experience. The salt-bath 
will be found in these cases invaluable, affording, as it does, increased 
vitality.* 

* To Professor Sigmund, of Vienna, are we indebted for an appreciation of 
syphilitic manifestations occurring where there is associated with the disease 
nothing of the ordinary history. Syphilis of the mucous membrane of the 
mouth and jaws [Wiener Med. Wochenschrift) is recognized as a second- 
ary or tertiary form of the disease commencing in the genitals or region of 
the anus. Those cases, on the other hand, are rare in which syphilis most 
undoubtedly, or with a probability amounting almost to certainty, occurs as a 
primitive affection of the oral mucous membrane, especially the lips, and 
thence extends to the general system. Professor Sigmund, in 1865, called 
attention to the increasing frequency of affections of the lips of primitive 
syphilitic forms, — indurations, papulee, ulceration, — and this opinion has been 
confirmed by subsequent experience in his own' private hospital practice. 
This observation has, in addition to its importance with regard to pathology 

37 



578 ORAL DISEASES AND SURGERY. 

Mercurial Necrosis. — Ostitis, and exfoliation from the undue 
use of the mercurials, are so common as to have come under the 
notice of almost every physician. These cases have generally a 
history regular and distinctive in progress. First is observed by the 
patient, while the medicine is being taken, a coppery or metallic 
taste ; quickly associated with this is an enlargement of the tongue, 
recognized through the indentations made by the teeth as the organ 
encroaches on these bodies. The next stage is a puffiness observed 
about the necks of the teeth, commencing generally with the inferior 
incisors ; the congestion of the oral mucous membrane, which soon 
extends over the entire cavity, produces a sense of dryness, and not 
unfrequently burning ; the tumefaction, which has now become gen- 
eral about the necks of the teeth, assumes a livid color, and presents 
a grayish, cedematous surface, which extends more or less widely 
throughout the mouth ; the inflammation, attended with its cacoplas- 
tic exudate, next intrudes on the alveolo-dental membrane, and the 
teeth soon become so loose as readily to be lifted from their cavities, 
and when so thrown off are found covered with the sticky, grayish 
lymph in abundance. 

and treatment, a deep social significance. From 1861 to 1867 seventy-three 
cases of these primary affections of the lips came under the notice of Profes- 
sor Sigmund. Of these, thirty-two were presented at the hospital, and forty- 
one in private practice. These seventy-three cases of syphilitic affections of 
the lips occurred out of 5551 patients. The disease was observed much more 
frequently in the upper than in the lower lip. The most frequent explanations 
as to the cause of its having been contracted were, in males, smoking, and the 
use of certain tools, and in women, the rubbing of a spoon against the upper 
lip, and also the habit of holding between the lips thin, sharp, and pointed 
instruments, such as are used in sewing, arranging flowers, drawing, painting, 
working in cardboard, and similar occupations. It is worthy of remark 
that these affections of the lips occur in all ranks of society. Professor Sig- 
mund passes over the special etiological reports appertaining to these affec- 
tions, as they are in many cases doubtful, and, moreover, savor of scandal. 
Labio-genital coitus could be clearly proved in some cases, and in others 
contagion "by means of paint-brushes, tobacco-pipes, drinking-vessels, etc., 
was made out. The syphilitic affections of special importance to the practi- 
tioner are those produced through kissing. Any method of transferring 
syphilis to a healthy individual from one previously affected at an earlier or 
later period, but evidently, and to a superficial observer, cured of the disease, 
is of the greatest importance ; and even these methods have, according to 
Sigmund 's experience, occurred with great frequency, and form a very note- 
worthy, but often neglected, mode of origin of the affection. 

Interesting cases of specific inoculation by kissing are recorded in con- 
siderable number in American medical publications. 



NECROSIS. 579 

Uncombated, the effect of the metal passes rapidly to the alveo- 
lar processes, this tissue seeming to undergo a process of liquefac- 
tion and absorption. Necrosis, when it ensues, may be partial or 
complete. Many interesting cases of such condition have come 
under the notice of the author, some of which will be found alluded 
to in other parts of this volume. Children, during the dentitional 
period, are found most in danger of mercurial necrosis, the parts 
seeming preternaturally susceptible : the result, without doubt, of 
the excitement related with dental genesis. When the mercurial 
poisoning is conjoined with the scrofulous condition, the ravages are 
found most marked. The writer has known a single two-grain dose 
of calomel in a child of this cachexia to kill half the lower jaw. The 
inflammation accompanying mercurial necrosis is apt, from its slough- 
ing tendency, so to destroy the neighboring soft parts that not 
unfrequently the mouth is permanently closed, requiring for relief 
plastic operations of the most difficult and complicated character ; 
and, unfortunately, even these proceedings are not always able to 
restore to the patient the lost offices of the parts. (See Operations 
on the Lips and Cheeks.) 

The state of salivation, so characteristic of the mercurial poison- 
ing, comes on at varying periods, the susceptibility being influenced 
by different conditions : the increase of saliva varies, also, from that 
which may scarcely elicit attention, to a secretion which shall keep 
the mouth of a patient constantly over a vessel. Persons occasionally 
are to be met with who will be salivated by the simple smell of a 
mercurial; there are others, on the contrary, who appear in this 
expression, at least, entirely unimpressible. It would seem to be a 
just experience that the mercurials, as a rule, should not be given 
to teething children, or to scrofulous subjects, and assuredly it can 
never be productive of good to push the medicine, let little or much 
be demanded, beyond that point at which its effects are observed 
upon the festoons of the gums. 

In the treatment of mercurial ulitis (which see) attention has 
been called to a practice by free scarification and the local use of. 
iodine. Many cases of threatened necrosis have by these means 
been aborted ; but very great care is to be exercised, that the low 
vital force be not still further depressed. 

The treatment that applies to ulitis applies also to ostitis. 

In the special treatment of the mercurial, as of any other seques- 
trum, it is to be looked upon as a matter of much importance that 
the dead piece be detached by nature alone, assisted bv the surgeon 



580 ORAL DISEASES AND SURGERY. 

only as in other paragraphs described. Particularly does this seem 
important in the young jaw, as thus it may happen that we shall 
not disturb, unnecessarily, the germs of developing teeth. 

Much stress has been laid by some practitioners on the preserva- 
tion of such teeth as are associated with the sequestrum, and advice 
given that incisions be made through the soft parts that shall allow 
the bone to be drawn away from the loosened teeth. Such treat- 
ment can certainly only apply to very few and peculiar cases. As 
a rule of practice, the author is confident it must be found of little 
signification. 

The ill odor and putrescence associated with mercurial necrosis 
are to be antagonized by the free use of antiseptic injections. 

Necrosis from Injuries. — Accidental injuries received by the 
jaws are not infrequent causes of necrosis. Having such origin, 
the recognition and comprehension of the condition are the appre- 
hension of the common pathological expression. Traumatic influ- 
ences capable of provoking an ostitis or periostitis, which may result 
in necrosis, may be independent of external wound, depending 
entirely on concussion.* The treatment of such cases is the treat- 

* " As a result of injury there are extravasations into the cellular'strueture 
of the bone ; also, perhaps, into the compact substance, and occasionally under 
the periosteum. If these ruptures of the vessels be so extensive that their 
results cannot be removed by collateral circulation, which is of difficult estab- 
lishment in bone, part of the bone will no longer contain any blood; this will 
die, and, according to circumstances, we may have central, superficial, or total 
necrosis. The portion of dead bone remains in the organism as a foreign body, 
but still continues in continuity with the healthy bone. What becomes of bone 
so destroyed? Dead bone may be dissolved and consumed by granulations. 
Hence we should expect that the elimination of the sequestrum would not 
require any aid. From my observations, I have no doubt that small sequestra 
may be completely consumed by proliferating granulations. Granulations 
that are being destroyed or undergoing cheesy degeneration have no power 
of dissolving bone.' We have already stated, when speaking of caries, that 
partial necrosis occurs so readily in atonic, suppurative, or caseous ostitis, 
just because the inflammatory neoplasia, which so quickly breaks down again, 
does not dissolve the bone, but leaves it to be macerated in the body. But the 
reabsorption of the sequestrum has its limits : first, of course, it ceases when 
the bone is uncovered, for here the granulations have no effect; it also ceases 
as soon as th.ej secrete pus on their surface : hence a sequestrum resulting 
from acute periostitis is not usually absorbed at the point where the perios- 
teum suppurates, and where pus forms during the whole process, because it 
does not come in contact with the granulations ; but at all points where the 
sequestrum must be loosened, reabsorption commences from the interstitial 



NECROSIS. 581 

ment of inflammation anywhere. Death of the bone, in whole or in 
part, resulting, the case has the common history of necrosis. 

Exanthematous Necrosis. — As a result of the exanthemata, it 
occasionally, though fortunately quite infrequently, happens that a 
subacute inflammation of the jaw occurs, resulting in limited or, it 
may be, extensive necrosis of the part affected. To this form of 
disease, as the recognition of its associations is concerned, atten- 
tion seems first to have been directed by S. James A. Salter, of 
Guy's Hospital, who records twenty-three cases as being met with 
in the associated population of that institution. The author in his 
own practice has now met with four cases, all of them being the 
sequel to measles ; and, unlike the condition as it seems most com- 
monly met with, the disease extensively involving the bone, — the 
lower jaw in three cases, the upper in one. 

The accompanying cut is from a photograph of pieces, constituting 
the full half of the lower jaw, removed from the mouth of a German 
boy six years of age. The earlier history of this case could only 
be procured to the extent of learning that some time after an attack 

granulation masses forming on the bone. Lastly, after the sequestrum is de- 
tached, if these granulations also produce pus, reabsorption ceases here also, 
and the sequestrum, bathed in pus, ceases to decrease ; the granulations of the 
pus cavity, growing from all sides toward the sequestrum, in the course of 
time undergo chemical change, — they become very gelatinous, mucous, and 
often undergo fatty degeneration. 

" But the sequestrum must finally come out. Can it clo so unaided ? This 
does occur. Whence the power that pushes it out? Let us suppose a central 
necrosis : a sequestrum becomes detached from all sides ; then it is consider- 
ably smaller than the cavity in which it lies. The piece of bone is now quite 
loose ; granulations grow toward it from all sides except from the one where 
the pus cavity opens externally. Here there is no resistance ; if the opening 
be large enough, the constantly-increasing granulations push out the seques- 
trum. But for this to occur, there must be certain mechanical conditions 
which are rarely fulfilled. Small sequestra are thrown off spontaneously; 
large ones, which cannot pass the existing openings, must be removed arti- 
ficially. 

"The treatment of necrosis consists at first, simply, in keeping the fistula 
clean. Chemical solution of the sequestrum is not to be thought of. If you 
were daily to pour muriatic acid into the fistulous opening, it would atfeet the 
newly-formed osseous tissue as much as, if not more than, it would the seques- 
trum, which would be very unfortunate, as it must replace the latter. Hence 
the mechanical removal of the sequestrum is the only thing; this should not 
be attempted before complete detachment. This is a very important rule." — 
Billroth. 




582 ORAL DISEASES AND SURGERY. 

of measles the child commenced to complain of a sore mouth, the 
gums swelling as in an attack of periodontitis, the swelling after 
a few weeks being followed by the continuous 
discharge of pus, which the parents stated 
had been troubling him for several months ; 
could not say whether it might be two or four. 
When first presented at the clinical service, 
the child was so emaciated that little hope 
a + ~ Z^tT^ " was entertained of saving" its life ; but, after 

Sequestrum after Measles. ° ' ' 

having been placed upon vigorous tonic med- 
ication for two weeks, taking iron and quinine, drinking beer, using 
salt-baths, and having the parts almost hourly syringed, thus 
washing away the offensive semi-putrid pus in place of allowing it 
as before to pass to the stomach, and at the same time using local 
means of a stimulating nature, the reaction was of the most prom- 
ising character, and invited and indorsed the attempt to remove the 
sequestrum. 

Making at a second clinic thorough examination, it was evident 
that the body of the bone in mass was dead, and that not the 
slightest attempt had been made toward the formation of any new 
osseous structure. In this instance, all proper attempt was made 
to excite the production of new bone, the necrosed structure only 
being removed when to leave it longer in its bed would have been 
to risk the life of the child. 

The removal of the bone in this. case resulted in a considerable 
immediate deformity, but which after two years had so completely 
disappeared as to be scarcely observed, while the natural motions of 
the jaw seemed quite as good as in other children. 

In a second case, the disease attacked the upper jaw, resulting in 
a repetition of small inflammatory sequestra, together with the 
crowns of the undeveloped bicuspidati of the side affected ; the dis- 
ease continuing, in defiance of treatment, for over a year, and yielding 
finally only to a summer spent upon the mountains. 

In the treatment of these cases, nothing special seems demanded, 
unless it might be that we should be able to recognize and admin- 
ister the specific for the peculiar poison. Lacking such knowledge, 
the case is to be conducted on general principles : great cleanliness, 
conjoined with stimulating and antiseptic injection, constitutes the 
principal local demand ; while systemically, the patient is to be 
supported under the drain which, to a greater or less extent, always 
attends the process of exfoliation. 



NECROSIS. 583 

In cases of slight signification, such as are referred to among 
others in the foot-note from Holmes, where the exfoliated part may 
involve but the edge of the alveolar process, so little attention might 
be demanded as to deny the surgeon even the opportunity to see 
such states of the condition.* 

* " I believe that the necrosis and exfoliation of the alveolar process and 
portions of the jaws in children, consequent upon the eruptive fevers, is 
essentially the same as the maxillary necrosis in the victims of phosphorus 
fumes, and that it is the result of the local application of a specific poison to 
the vascular parts of the teeth. There is this difference, however, that in 
the case we are now considering the poison is generated within the individual, 
but with affinities for certain structures and tendencies to action upon certain 
organs, which give its morbid consequences an equally local character. What- 
ever opinions may be entertained as to the homological relations of the several 
tissues of the teeth to those of the general integument, there can be no ques- 
tion as to their being members of the dermal system, and as such we should, 
a priori, expect that they would share the consequences which attend those 
particular diseases which spend their chief force on the skin. There is one 
circumstance, however, that modifies such an anticipation : it is the low 
state of vitality of the teeth, and the extremely slight nutritional changes 
which occur in them when once they are formed, and which must conse- 
quently remove them to a great extent from those transient, though potent, 
influences which would destroy or morbidly affect vascular or growing tis- 
sues. But such a qualification does not apply to the conditions of the teeth 
during their development. From the time of birth until the eighth or ninth 
year, the jaw-bones are the seat of intense developmental nutrition in the 
formation of the teeth, and are among the most vascular parts of the body. 
About the middle of the period named, five years of age, the maxillae con- 
tain no less than forty-eight developing teeth and developing tooth-germs. 
It is about this time that the poison of the exanthematous fevers appears to 
exert its most deadly influence on the dental system. 

"The form of necrosis affecting the alveolar edges of the maxilla, and 
accompanied by the shedding of the teeth, which we 'are now considering, 
was, I believe, first recognized by myself (Transactions London Pathological 
Society, vol. xi. pp. 209 to 215) as one of the sequelae of the exanthemata, 
and dependent necessarily on their previous occurrence. Many isolated cases 
of the affection have been described, and our museums contain specimens of 
the sequestra ; but the supposed relation of cause and effect has not, so far as 
I know, been expressed before. (The earliest recorded cases are mentioned 
by Fox in his ' History and Treatment of the Diseases of the Teeth,' p. 112, 
London, 1801. These cases, two in number, occurred after smallpox.) 

"This affection is by no means common, considering the almost universal 
occurrence of the eruptive fevers. The very large population tributary to 
Guy's Hospital has only furnished me with twenty-three or twenty-four cases 
during the last nine years ; and I have reason to think that even in this I 
have been disproportionately favored. 



584 ORAL DISEASES AND SURGERY. 

Phosphor-Necrosis. — This is a term applied to that necrosis of 
the maxillary bones dependent on phosphorus-poisoning, being a 
disease peculiar to workmen in match-factories, and confined here 
almost exclusively to such as are engaged in the processes of dip- 
ping and packing. How phosphorus affects the maxillary bones, 
whether from a systemic or a purely local relation, continues to excite 
discussion. That persons possessed of carious teeth are alone af- 

" The cases are all singularly alike. A little child has just recovered from 
one of the eruptive fevers, most probably scarlatina ; the case has been in no 
way unusual as to its severity or its course. Within six weeks or two months 
of the passing off of the acute symptoms, tenderness of the mouth is com- 
plained of, and the mother notices fetor of the breath. Upon inspecting the 
mouth, the gum is seen to be peeling from the edge of the jaw around the 
neck or necks of some temporary tooth or teeth, pus is discharging, and more 
or less dead bone is exposed. The denudation of the bone progresses rather 
quickly in depth, but usually not after the first in lateral extent. The tem- 
porary teeth at the affected part become loose, and often fall out. There is 
no swelling, and no ossifying callus is formed in the region of the necrosed 
bone. In a few weeks from the first of these symptoms the sequestrum be- 
comes loose, and is easily removed, leaving a large gap and a raw, granulating 
surface, which rapidly heals. The necrosis almost always includes the bone 
which constitutes the loculi containing the developing permanent teeth, as 
well as the alveoli of the temporary ; but it does not go further, and in the 
lower jaw the base of the bone is very rarely affected, — note clinic case 
recorded. I have never seen such an occurrence. The disease is frequently 
symmetrical. When attacking the bone about the temporary molars on one 
side of the jaw (its most common situation), it often manifests itself immedi- 
ately after on the opposite side, and sometimes in the same regions of the other 
jaw. The same symmetry is observed in front of the mouth. 

"As far as I am aware, this affection only occurs after the eruptive fevers, 
and scarlatina is its most potent cause. In the instances which have been under 
my own care, two were after smallpox, five or six after measles, and fifteen or 
sixteen after scarlatina. There is, however, nothing in the condition of the 
mouth to indicate which has been the precursor. The age at which this affec- 
tion occurs is usually about five years : from three to eight are the extreme 
limits I have known. 

" The issue of these cases is simply comprised in the loss of a certain amount 
of bone with the contained teeth, and the consequent disfigurement. As the 
permanent teeth are lost with the temporary, the disfigurement is very great 
when it affects the incisors ; but when the temporary molars, and their suc- 
cessors, the bicuspids, suffer, the damage is comparatively slight. 

" The treatment of these cases involves little beyond patience and cleanli- 
ness. ISTo operative interference is indicated ; the extent of the necrosis asserts 
itself from the first, and cannot be curtailed. When the sequestrum becomes 
loose it is to be taken away." — S. J. A. Salter — Holmes. 



NECROSIS. 585 

fected, seems sufficiently verified; while, on the other hand, as shown 
first by Dr. Letheby, of London, phosphorus has a systemic relation, 
as exhibited by its detection in excess in the urine of the poisoned 
patients. Yon Bibra and Geist, holding to the theory of a local 
contamination, direct attention to the fact that "toothache invaria- 
bly precedes the more severe affection," that a carious state of some 
tooth or teeth is a "sine qua no7i," and that "so long as the teeth 
remain good the affection does not show itself." Lorinser, who was 
the first to describe the phosphorus-disease, holds to the analogy of 
the affection with the mercurial poisoning, — a view which the 
experience of the author of this volume leads him markedly to 
sympathize with, although it is not to be denied that such view 
is markedly in opposition to that which at the present time is 
generally held: this common view being that phosphorous oxide, 
in a low form, finds a way to the periosteum through the dental 
pulp canal, producing, as a result, this peculiar and specific inflam- 
mation.* 

A jaw, however, fretted and vascularly excited by teeth in a state 
of disease, would naturally be expected to be in a more susceptible 
condition than one strictly healthy: hence it might very well be 
that such special susceptibility could explain the attack, the natural 
resistive force of the part being to such extent lowered. Such 
supposition certainly tends to add force to the views of Dr. Lorin- 
ser, "that the fumes act by infecting the blood, laying the primary 
foundation for a disease which remains dormant until an exciting 
cause fixes the spot for the outbreak." In proof of his inference, 
attention is directed by Dr. Lorinser to the peculiar dirty sallow, 
combined with a dull, expression, together with the gastric derange- 
ments, which are prodromous to the local affection ; expressions 
which the author has observed as characterizing his own patients. 
In certain Nuremberg patients, however, mentioned by Yon Bibra 
and Geist, these prodroma were not only lacking, but, on the contrary, 
the majority were seen to be of healthy, florid complexions, which 
some retained to the last stage of the disease. Let the true 
expression of the case be as it may, a prophylaxis always to be 
commended to workers in phosphorus is found in that continuous 
attention to the mouth and teeth which insures the most perfect 
cleanliness, combined with the immediate filling of every tooth, 
which becomes carious, thus preventing exposure of the pulp. A 

* For arguments, see Clinical Lecture by Mr. Simon, Lancet, 1850. 



586 ORAL DISEASES AND SURGERY. 

second prophylaxis is one suggested by Mr. Salter (see Holmes), 
who expresses the belief that by keeping the atmosphere of the 
factories ammoniuretted, and thus neutralizing the acid vapor, few, 
if any, cases of the disease would ever occur. 

Still another means having general commendation is found in the 
emplo} r ment of a respirator, of which perhaps the best is that de- 
vised by Mr. Graham for persons exposed to carbonic acid vapor. 
This consists of the mixture, in equal bulk, of fresh-slacked lime 
and sulphate of soda, worked into a cushion, through which it shall 
be easy to breathe. Carbonate of magnesia, used in teaspoonful 
doses twice each day, and applied with all freedom locally, will be 
found of great service in antagonizing the acid. 

Outside of the association of the patient with phosphorus, there 
is nothing which, to an ordinary observer, would distinguish the 
incipient condition of this loathsome disease from a case of severe 
periodontitis. 

The first sign of a commencing phosphor-necrosis is found com- 
monly in one or more teeth becoming sore to the touch, feeling, 
on occlusion, as if raised in their sockets ; in a short time the sur- 
rounding gum begins to swell : in the character of this swelling is 
the first distinctive sign. It is not the acute, firm, inflammatory 
swelling of periodontitis, or of traumatic ostitis, but from the begin 
ning has a puffy, debased, and degenerating look. One feels as if he 
might hesitate in adopting any very decided antiphlogistic treatment, 
or, indeed, in employing any other than an expectant one. (See 
case from Yon Bibra and Geist.) 

Phosphorus acts both on the upper and the lower jaw-bone, but 
seems to have a decided predilection for the lower ; as twelve to 
nine, perhaps.* 

The history of a case of phosphor-necrosis might be epitomized 
as follows : a degenerative inflammation commences in the alveolo- 
dental membrane, or in the substance of the bone ; the author in- 
clines most strongly to the belief of its commencement in the latter. 
The degeneration of this bone progresses until its enveloping peri- 
osteum — which remains unaffected as its vitality is concerned — 
separates from it. The bone dies in bulk, or in part. In the lower 

* Of twenty-two cases reported by Dr. Lorenser, nine were of the upper 
jaw, twelve of the lower, and one in which both were affected. Of fifteen 
cases occurring in Nuremberg, five were in the upper, nine in the lower, and 
one in both. Of eight cases recorded by Dr. Neumann, three were of the upper 
jaw, four of the lower, and one of both. 



NECROSIS. 587 

jaw, the body alone commonly dies, the rami remaining unaffected. 
In the upper, one cannot well infer where the demarkation will 
occur. During this process of death, the periosteum, particularly in 
the lower jaw, is most active in the reproduction of new bone, osteo- 
phytes, so called ; this new material exhibiting markedly its endeavors 
to envelop and replace the old. The separation of the dead from 
the living bone, in the lower jaw, when the dead part is at all exten- 
sive, will be found most likely to occupy a period of from seven to 
nine months, and is apt to be attended with the formation of many 
sinuses, both in the mouth and about the neck, being very ex- 
haustive to the patient, both on account of the great suppurative 
drain and the nauseating character of the discharge. All the soft 
parts associated with the affected jaw, the periosteum perhaps 
excepted, sympathize warmly during the process of the dying and 
separation, looking, indeed, as if very badly affected with scurvy. 
At the period above alluded to, the separation being completed, the 
surgeon may remove, with little effort, the sequestrum; the sinuses 
then heal, and the parts may recover with as little deformity as 
attends the extraction of the teeth and the ordinary absorption of the 
alveolar process. 

This, I think, will be found a common history of the disease. The 
author has seen and treated many cases, and it is thus that it has 
presented itself to his observation. It might perhaps be added 
that the teeth, influenced by the advancing disease, loosen one by 
one, so as to make necessary their removal long before the bone is 
ready to come away. 

In phosphor-necrosis the death of the bone seems to be a result 
of morbid porosity, the loosening and expansion of the structure 
proving antagonistic to its nutrition; as vitality diminishes, so, as the 
result of a cacoplastic exudate, the periosteum is found to separate 
itself, such secretion explaining, in its degeneration, the character- 
istic abundance of fetid pus. Indeed, it is to be seen almost from the 
earliest affection of the bone that the periosteum is aroused to 
efforts for self-protection ; so marked is this in many instances that 
attempts at the formation of new bone separating the periosteum 
from the dead tissue result in numberless osteophytes, if indeed a 
perfect wall is not secured. The writer has seen not unfrequently 
the whole floor of the mouth, back to the base of the tongue, occu- 
pied by such new bone. 

As is to be readily recognized, however, the tendency of this 



588 ORAL DISEASES AND SURGERY. 

exudate to degeneration is marked: thus, the osteophytes are found 
in inverse proportion to the quantity of pus. These osteophytes, 
in characteristics, are seen also to be greatly influenced by a treat- 
ment employed in a case : in the beginning they are, it is to be 
inferred, uniform ; from such uniformity we see them as slender 
shreds, in masses, and indeed in every irregularity of form and 
feature ; decidedly disposed also are they to break down and disap- 
pear, and this particularly where extreme cleanliness is not observed 
or the system at large is left without the support of tonic medica- 
tion. It is, indeed, simply the common history of lymph degenera- 
tion, — an inability on the part of the plasm to the maintenance of a 
self-supporting organization. 

A dull, dirty -yellow complexion, as has been remarked, is almost 
universally associated with phosphor-necrosis: this has been variously 
attributed to dyscrasia, to the pain, the impeded ingestion, and to 
the immense drain made on the system in the progress of the ex- 
foliative process. The most reasonable hypothesis is that all these 
causes are alike implicated: certain it is, that to- get a patient 
clear of such a complexion, all require to be considered in the treat- 
ment. 

The tendency to the burrowing of pus in acute phosphor- 
necrosis is remarkable, and to a marked extent will such burrowing 
occur in defiance of treatment : if the lower jaw is the seat of the 
disease, the sinuses will riddle the neck ; if the upper, the antrum 
tends to receive the pus, while in grave cases it not unfrequently 
finds its way to the ear and the mastoid process of the temporal 
bone. 

Salivation is another of the marked characteristics of the condi- 
tion : the author has had patients who were compelled to have a 
handkerchief constantly at the mouth to receive the drainage. 
Another source of discomfort resides in vomiting: particularly 
does this tend to occur in the morning, the result of the pus swal- 
lowed during the night. Fever, diminution of appetite, and de- 
rangement of the bowels follow the progress of the disease, and, if 
not vigorously combated, are apt to end in an inanition fatal to the 
patient. 

The sequestra of phosphor-necrosis in the lower jaw look some- 
what like pieces of rotten sponge, being almost as light and porous ; 
this arises from the suppuration and discharge of the primary 
exudate which was the cause of the original enlargement : the 



NECROSIS. 589 

organic material being all discharged, nothing remains but the cell- 
riddled, inorganic structure, hence the brittleness. 

Treatment. — The treatment pursued in phosphor-necrosis is to 
consist in the employment of means which shall circumscribe as much 
as possible the disease, which shall hasten the process of limited 
death and the accruing separation, and which shall support the 
patient under the drain to which he is necessarily subjected. 

When a case presents in its incipiency, that is, simulating a de- 
veloping periodontitis, we commence the local treatment just as we 
w r ould that of the periodontitis. If the inflammation has about it 
anything of a healthy acuteness, we limit as much as possible all ex- 
ternal irritation, by softening in the gas-flame or by the stove a piece 
of gutta-percha, and moulding it over some opposite tooth, or tooth 
farthest removed from the seat of trouble ; a mouthful of cold water 
hardens this cap, and thus occlusion against the sore tooth or teeth 
is prevented. A dose of Epsom salts or other saline cathartic is 
ordered, and a sinapism is applied to the back of the neck. A hot 
pediluvium is found sometimes to act very happily as a derivative; 
or a diaphoretic, such as the spirits of Mindererus, may serve a 
very good end. Depletion by leeches, however, has never seemed 
to the author to be an indication : the affection has its very origin 
in asthenia. 

If we first see the case — and this is most apt to occur — when a 
discharge has made passage for itself by opening through the gum 
at the neck of a certain tooth or teeth, we immediately make a free 
incision through the soft parts down upon the bone, and syringe the 
parts thoroughly with some medicated water, stimulating or antisep- 
tic, or both, as indicated. Having the parts well cleansed, we stuff 
the wound which has been made, with cotton or sponge. This is 
repeated the next day and the next, until, particularly as the syring- 
ing is concerned, it may be absolutely necessary to repeat it a dozen 
or twenty times per diem, the progress of the disease being so 
marked by discharge and offensiveness. As day by day the cotton 
or sponge stuffing is renewed, it is insinuated gently between the 
separating periosteum and bone. This manipulation will be found 
to hasten the separation wonderfully, and expedite the cure of the 
case. 

It might here be asked, perhaps, by some one, " Is not this pro- 
cess of working off the periosteum an unsurgical proceeding, com- 
pelling an extension of the disease beyond that which would have 
been the result if left to itself?" The author can only answer from 



590 ORAL DISEASES AND SURGERY. 

his own experience in different modes of treatment, and say that he 
is perfectly satisfied that this is not the case, and that the result 
is for the good of the patient in every way: the portion of bone 
destined to die has the destruction markedly hastened ; the sooner 
the death, the sooner the separation ; the sooner the separation 
and exfoliation of the sequestrum, the less exhaustion to the 
system. 

The compound tincture of capsicum, with an excess of myrrh and 
an addition of the permanganate of potash, is an excellent wash for 
the mouth in these cases. Cold water, with a little salt and mag- 
nesia dissolved in it, can be used ad libitum. 

The sinuses which are so apt to form upon the neck, in defiance 
of all treatment, and which greatly annoy by their discharge, are 
most comfortably treated with dressings of patent lint. Once formed, 
it is a waste of time to attempt the healing of them : they will only 
get well when the source of offense in the dead bone is removed. 

It has been remarked that the death is limited in the lower jaw 
to the body of the bone, the horizontal portion, the demarkation oc- 
curring at the angle. This, in the majority of instances, will be seen 
to be the case, particularly if the treatment has been properly directed. 
Seven months has been found, in the practice of the writer, the 
minimum required for the course of the disease, nine months the 
more common time, and fifteen the maximum, although this latter 
does not accord with German experience, cases being reported of 
two years and a half standing. The drain during most of this time 
is immense, the patient requiring the most generous tonics and sub- 
stantial fare. Attention to the repair of this wear and tear is, per- 
haps, of greater consequence than any local treatment ; certainly, if 
one could not have both, his chances would be best with the former. 
Both are to be esteemed as of vital consequence. To commence, 
however, with the ordinary medicinal tonics, is ill advised. One 
cannot well keep on with them, and by employing them in the begin- 
ning of the disease we lose their powerful assistance at a time when 
every help is found weak enough at the best. Good underdone 
roast beef is quite enough for the first two or three months ; then 
an addition may be made of generous malt liquors, together with 
the salt-bath. The latter portion of the time will demand iron, 
quinine, brandy. The hemorrhages, sometimes so profuse, are held 
very well in check by the exhibition, once or twice weekly, of five- 
drop doses of tincture of Erigeron Canadense. 

The period at which a sequestrum is ready to be taken away can 



NECBOSIS. 591 

only be known by repeated examination, the proper treatment being 
to wait always until the separation is complete, be such time longer 
or shorter. Nothing, the author is satisfied, is gained by expediting 
the removal through operative proceedings, as by breaking away 
the bone, using the chain-saw, etc., while the risk to life is very 
considerable. To wait patiently, keeping the system equal to the 
demand on it, is the surgeon's highest duty; to do more is to do 
harm. 

The removal of the bone is always to be effected from the inside ; 
it does not seem that an outside incision would ever be found neces- 
sary. If the opening along the gum, obtained in the treatment, be 
not great enough, it is easily enlarged to an extent desired. 

A step preliminary to the removal of the body of the lower jaw 
is its division at the symphysis. This is most easily accomplished 
by means of the straight-cutting forceps. It is better to cut little 
by little, from above downward, than to crush through the bone with 
a single cut ; it does not hurt or shock nearly so much. The opera- 
tion is not a severe one, seldom demanding the patient to be ether- 
ized, yet it is generally enough to be borne at one sitting. 

To take away the bone, no instrument is found better than the 
ordinary tooth forceps, such as is in common use for the extraction 
of the inferior incisors and bicuspidati. With such forceps, com- 
plete control of the part is secured, and the removal, as a general 
thing, easily effected. 

A trouble frequently encountered, and one which, undistinguished, 
would prove confusing and deceptive, consists in the grasping of the 
sequestrum, when extensive, by the lateral overlying tissues, — not 
by the new bone, but by the indurated soft parts. The writer recalls a 
case which he once had under treatment, where, the dead bone being 
thus held, the practitioner had been waiting for the separation a 
period of over two years, being deceived entirely as to the condition 
of the part. To satisfy one's self as to the condition, pass a small hook 
under the bone, and lift : if the bone yields springy, it is only thus 
held, and may with safety be pulled through ; if, on the contrary, it 
is firm and unyielding, it is to be left alone, — separation has not yet 
taken place. 

In the reproduction of the new bone, which, at the period for the 
removal of the old, should be found to have obtained such character 
as to keep up perfectly the shape of the parts, the observer will be 
struck with the excess deposited along the middle line of the mouth : 
it seems, oftentimes, as if the floor was a mass of bone, — which, 



592 ORAL DISEASES AND SURGERY. 

indeed, it really is. It will not be found necessary, however, to do 
anything with this excess, nature taking all proper care of it. 

Phosphor-necrosis attacking the upper jaw seems not so much to 
be dreaded as that associated with the lower. It is seldom so for- 
midable in its nature or so destructive in its progress, the disease in 
these parts having been seen to run its whole course with an entire 
absence of acute action. A portion of bone dies, and the surround- 
ing soft parts seem utterly indifferent. One would scarcely know 
anything abnormal was going on, were it not for the indication given 
in the loosening of the teeth ; these drop out somewhat as they 
would out of the dried skull, while the soft parts eventually present 
the appearance of shrinking away from the bone, which structure 
becomes fully exposed, — as dry and lifeless, apparently, as that of 
any dead skull. This, however, is, of course, not the common his- 
tory. The inflammatory action is of the same type as that associ- 
ated with the disease in the lower jaw, but more limited in extent 
and consequence, and much more susceptible to remedial measures. 
A bad feature consists in a marked tendency to recurrence of the 
trouble ; but this, perhaps, will mostly be found within the control 
of the surgeon. The removal of a sequestrum here is a 'trifling 
matter, comparatively little dissection letting the piece pass. If the 
bone seems grasped by the contracting soft tissue, the easiest plan 
of removal will be found in the introduction between the parts of 
pellets of cotton : these quickly swell, and thus effect loosening. 

At a Medical Congress in Zurich, Switzerland, Professor Billroth, 
in citing his experience with phosphor-necrosis, remarked that in 
attacking the upper jaw it seemed to act with greater and more 
destructive force, and was more unmanageable. 

The author does not know how to reconcile these differences in 
clinical observation, unless an explanation may be found in the im- 
plied greater tendency to return which exists on the part of the dis- 
ease when situated in the upper jaw. In the lower jaw, the full 
part that is to die seems impressed from the beginning, — that is to 
say, a certain portion seems predestined, and it dies in defiance of 
all you may do. Not that the evidence of the disease is general 
over all the involved part from the beginning : on the contrary, the 
incipient stage is markedly localized ; but then, day by day, and 
week by week, the trouble extends over the apparently predeter- 
mined or preimpressed part. When the death occurs, it is a single 
death ; and when the piece is cast off, there is not apt to be any 



NECROSIS. 



593 



Fig. 228. — Appearance of Patient 
with Phosphor-NecpvOsis. 



renewal of the trouble. The sequestrum of the upper jaw, on the 
contrary, is generally small, some portion, most likely, of the alve- 
olar process ; but unless the treatment is of the most supporting and 
specific kind, it is apt to repeat itself, again and again ; but your 
treatment will be responded to here, and thus, with care and atten- 
tion, you have the amount of destruction comparatively under con- 
trol. If it is found more unmanageable in Zurich, then the means 
would not seem to be so well adapted to the end as those here em- 
ployed, or otherwise the circumstances must be different. 

Again, at the same Congress frequent resections are commended. 
To be so commended, they must, of course, have been found to 
answer a good purpose. The 
patients who have their jaws 
resected for phosphor-necrosis 
disease in this country gener- 
ally die, or, if happily they 
escape death, they do not find 
their disease cured without an 
inflammatory sequestrum at last. 

This case (Fig. 228), taken 
from life, represents a patieut as 
he appeared with the disease 
five months in progress. At 
the end of eight months the 
writer removed the jaw at the 
articulation : the loss was very 
fully repaired at the date of 
operation, the parts having excellent motion. 

An important objection to the operation of resection, even were 
the question of life not involved, is the great resulting deformity. 
Let nature take her course, and of this there may be little or none. 
A late patient was a gentleman for whom the author removed — or 
rather from whose mouth nature cast out — the whole body of the 
inferior maxilla, and no one might tell whether it had been a case of 
necrosis or of simple extraction of all the inferior teeth, with the con- 
sequent alveolar absorption, so perfect has been the repair in accord- 
ance with the destruction. The objection that this new bone keeps 
up the trouble, by becoming involved in the diseased action, is not 
according to the experience of the author. If it becomes involved, 
it would seem to imply that it has not been properly cared for. Care- 
ful and properly repeated syringings with water medicated with 

38 




594 ORAL DISEASES AND SURGERY. 

iodine and creasote will protect it. This experience does not, how- 
ever, include the isolated osteophytes ; these do without doubt incline 
to degeneration and decomposition, but by care the many may be 
stimulated to a self-supporting combination to which the periosteum 
becomes what it was to the bone exfoliated. 

It is certainly most unfortunate that in the case of the upper jaw 
no osseous repair seems attempted, but it is not the experience of 
the author that the horrible deformities mentioned by various 
writers are at all common. Local and systemic stimulation combined 
with a tonic treatment insures more or less attempt at supporting 
the surrounding parts by an exudate which assumes a fibro-carti- 
laginous aspect, and which will assume the duties of the structure 
lost, to very good purpose. 

In loss of structure in the lower jaw the most vigorous efforts 
are seen to exist on the part of the periosteum almost from the be- 
ginning to reproduce the impressed part, disproving to such extent, 
as it would seem, the deduction of Dr. Geist, that the phosphor- 
ostitis is secondary to periostitis, for assuredly is it the case that 
under no circumstances of excitation does this tissue exhibit higher 
vitality. That this secondary deposit differs from the original bone, 
in possessing an excess of organic structure, implies perhaps only 
that the deficiency in inorganic substance has its explanation in the 
presence of the corroding acid of the disease. That the capsule 
of new bone is so frequently found to atrophy may have similar 
explanation with the primary osteophytic degenerations, requiring, 
if not a local, yet a constitutional care. A suggestion made by Mr. 
Salter that the new bone be supplied with function by using it as 
soon as possible as a base for artificial teeth may be found to have 
in it much practical import.* 

* As a study, having associated with it a post-mortem, and which must 
indorse the hints furnished in the body of this paper, attention is directed to 
the following, taken from Yon Bibra and Geist. The reader, however, should 
be impressed with the inadvisability of any treatment by depletion. 

"Barbara Keim, aged twenty-two, a well-made, under-sized brunette; of 
healtby constitution; menses regular, no morbid predisposition, not scrofu- 
lous ; had been engaged for four years in a lucifer manufactory in counting 
the matches, which at that time was done in the drying-room. 

"During the first three and a half years she remained perfectly healthy; 
during the last half year she had occasionally suffered from toothache on the 
right side of the lower jaw, but to this she paid little attention, as she had 
formerly been subject to toothache, and had lost several teeth by caries. As 
the pain only occurred periodically, she was not induced to quit her occupa- 



NECROSIS. 595 

tion. At the beginning of February, 1843, the toothache on the right side 
of the lower jaw became more severe, it ceased to be limited to the carious 
teeth, and extended through the whole jaw, over the cheek, and even to the 
temporal region and the neck. At the same time considerable febrile dis- 
turbance, with occasional rigors, supervened, accompanied by swelling of 
gums and cheek, with erysipelatous redness of the latter. February 4, she 
was admitted into the hospital. The examination showed the right cheek 
much swollen, and very tense towards the eye, the mouth, the chin, and neck; 
the tension most considerable in the vicinity of the lower jaw. Pain deep- 
seated, throbbing, piercing, concentrated at the angle of the jaw, and radiat- 
ing thence over the adjacent soft parts. Extreme tenderness on pressure. 
The gums of the diseased side of the jaw much swollen, tense, darkened, and 
tender; the mucous membrane of the cheek equally so; between the angle 
of the jaw and the first molar, thick, fetid pus of a phlegmonous character 
oozed out on pressure. 

"The first and fourth molars on the right side of the lower jaw were 
carious ; the other molars deficient, incisors and canine sound. Tongue 
furred, bitter taste, pain in forehead, oppression at epigastrium, ructus, nau- 
sea, constipation, inflammatory fever. 

" Ordered, an emetic, fifteen leeches at angle of jaw, a laxative to follow, 
and a gargle of oxymel and aq. flor. sambuci. 

"Evacuation of a large quantity of acid and acrid saburra. Eelief of 
general symptoms ; gradual progress of local affection. The swelling of 
gums increased, became more tense, extended to the soft palate; dysphagia 
and salivation supervened ; and the jaw became almost immovable. Sup- 
puration increased, pus laudable, but fetid. Ordered eight leeches to angle 
of jaw. Ung. hydr. with ol. hyosc, to be rubbed in, nitre mixture, iodine 
externally and internally. Poultices. 

" During the second week, the four incisors and one molar became loosened, 
suppuration ichorous and rusty, gums softened and livid, formation of sinuses 
on the external and internal surface, through which the probe reached the 
bone, which appeared in part rough, in part smooth. Pain lessened, extreme 
exhaustion. Commencement of cough and hectic symptoms. In the pro- 
gress of the disease, increased retraction of gums from the alveolar surface, 
fresh abscesses, increased discoloration, and burrowing sinuses, so that the 
entire side of the jaw was exposed to the probe, both externally and internally. 
The bone appeared almost entirely detached from the soft parts, floating in 
an excessively fetid sanious fluid. The first and fourth molar and the four 
incisors either fell out or were taken away by the fingers. The swelling of 
the cheek, over which there was a frequent livid flush, remained undiminished, 
but it yielded more to pressure, apparent fluctuation at one or two points, 
but no pointing of abscess externally. The lips and eyelids became cedema- 
tous ; and during the latter weeks of the patient's existence, the left cheek 
also became painful and swollen. The affection had thus reached the stage 
of gangrenous destruction of the soft parts ; the pain ceased almost entirely ; 
but there was a gradual increase of the hectic symptoms; and in spite of 
tonic and antiseptic treatment, the patient died on the seventy-third day of 
the illness, worn out by hectic. 



596 ORAL DISEASES AND SURGERY. 

"Post-mortem, eight hours after death. 

" Extreme emaciation, right cheek swollen, soft, livid. On heing detached 
from the edge of the lower jaw, a rusty, grumous, highly offensive, and 
greasy fluid exuded. Neither gums, periosteum, nor muscles of the cheek 
were distinguishable. All those soft parts appeared to be dissolved in the 
grumous fluid, which was inclosed in the integument of the cheek as in a 
pouch. The right half of the inferior maxilla perfectly denuded, and void 
of all connection with the soft parts in this grumous mass, so that after divi- 
sion of the capsular ligament it was extracted without the least difficulty. 
In the lungs, tubercular deposition; but neither softening nor suppuration, 
which accorded with the previous symptoms, as nothing had indicated the 
second and third stages of pulmonary phthisis. No tubercles in the mesen- 
teric glands. Anaemic and flabby state of the chief organs, the heart, liver, 
spleen, and kidneys; the blood in the large veins very thin and blackish. 

" Description of inferior maxilla. — On the external and internal surface of 
the ramus of the right side, there is a deposition of new osseous matter, partly 
accumulated in large masses, partly in small isolated portions round the neck 
of the articulating process, without affecting the glenoid surface, extending 
along the external and internal surfaces of the condyle and the coronoid pro- 
cess to the angle of the jaw. The deposit is extremely delicate at the neck, 
and where it forms the detached portions, increasing in compactness and size 
as it descends, so as to present a thickness of from a line to a line and a half 
at the angle of the jaw, where the deposits of the two sides join, without at 
all points being in actual contact with the bone of the jaw. On the inner sur- 
faces of the maxilla the deposit extends almost to the chin. At the alveolar 
processes of the incisors, there are three larger insular deposits. On the ex- 
ternal surface this new formation reaches to the fourth molar, and there are 
smaller deposits on the alveolar process of the right carious tooth. There 
are also two delicate deposits on the left side in the region of the first and 
second molar. 

" The new deposit is everywhere but loosely attached to the subjacent bone, 
has no organic connection with it; the thinner portions may be easily removed 
by the nail, and the surface of the exposed bone appears perfectly smooth. 
Some parts of the former decay, and separate spontaneously, which, however, 
is not the case in the more compact mass attached to the angle of the jaw. 
The more delicate portions of the deposit present a porous structure, resem- 
bling a fine sponge, an appearance due to the innumerable vascular orifices. 
In proportion as the deposit descends, and becomes more compact, the spongi- 
ness diminishes, and at the angle of the jaw the surface is much smoother, 
and the vascular orifices less numerous. The new deposit is partly of a dingy 
gray color, partly having a yellowish or a brownish or reddish tinge. The 
alveolar process, at the right and left last molar, is perforated, and looks cor- 
roded. The alveoli, which are open, present nothing abnormal. The bone 
of the maxilla itself presents throughout a smooth surface, even under the 
new formation, and must be considered, so far as external signs serve as an 
indication, as a perfectly sound bone." 

As a clinical case, having in it a valuable lesson, the author may add the 
following from his own practice. On a date forgotten, a father presented for 



NECROSIS. 597 

treatment a daughter with the communication that she had a very sore tooth, 
and that her wedding being appointed for the third following day, it was 
hoped she might be cured by that time. Examining the mouth of the patient, 
a periosteally diseased tooth was at once recognized, but the gum about it 
was so debased and puffy as to imply almost to a certainty more extensive 
disease and to suggest phosphor-poisoning, the fact of which poisoning the 
information that the girl worked in a match-factory at once verified. To tell 
this patient that her wedding must be deferred for a year, and to explain the 
long tedious treatment necessary for her cure, was to provoke a fainting-fit 
and quite a disagreeable scene. 

These people, both father and daughter, were quite intelligent, and much 
trouble was taken to explain the principles of treatment and cure, and par- 
ticularly to make understood the great demand necessarily to be made on their 
patience and endurance. 

Seven months this case was under care, being seen every third day, and 
treated precisely as suggested in the body of this chapter. At the end of 
this period the body of the bone was found loose in its new envelope, excepting 
that the ramus of one side had not quite separated. This objection to an 
immediate removal was explained, and directions enjoined to continue treat- 
ment for another month, when in every probability the whole jaw would be 
capable of being lifted away without trouble or pain ; while at the same 
time the preservation of the contour of the face would be secured by the new 
jaw which was being formed. Ill advised, the girl, losing faith in a treat- 
ment which necessarily seemed to be going from bad to worse, discontinued 
her visits. When next heard from, she had invited the operation of expe- 
diting the removal of the sequestrum by a saw-cut at the line of demarkation, 
and which resulted in death within a week. 



CHAPTER XXIX. 

WOUNDS OF THE MOUTH AND ASSOCIATE PARTS. 

Wounds of the mouth and associate parts have, of course, the 
signification of wounds in general. Thus, some are of an incised 
character, being slits or incisions made accidentally or purposely by 
sharp-edged instruments. Some are lacerated, contused, or torn, 
being made by dull and blunted instruments ; some are punctured, 
being made by pointed but not sharp instruments; some are pene- 
trating, as when the offending agent passes through the lip or cheek 
into the oral cavity. A wound may be of a compound or compli- 
cated nature, as, for example, in the case of blows or falls, which, 
while they cut and contuse the lip or cheek, break, at the same time, 
the teeth or fracture the jaw; gunshot injuries, lacerating or simply 
puncturing the soft parts, comminuting the hard ; bites of rabid 
animals, introducing a virus ; syphilitic inoculations, etc. Compli- 
cations may also be considered as embracing hemorrhage and shock 
as primary associations ; inflammation, with its varied phenomena, 
erysipelas, pyaemia, tetanus, etc., as secondary associations. 

Every wound presents a first indication. If an individual receives 
a hurt which covers the injured part with earth or other foreign 
substance, such substance is to be washed or taken away as the 
primary step. If hemorrhage is the feature, arteries are to be 
ligated, or other necessary means taken to control such bleeding. 
If shock be present, this is the most immediate feature, and is first 
to be combated. If a rabid or poisonous animal has inflicted the 
wound, the destruction of the virus is a first indication. 

Foreign Particles. — To remove earth or similar foreign parti- 
cles, no better means can be employed than the simple sponge and 
water. Holding the injured part over a basin, squeeze water upon 
it from the sponge ; if the particles are not washed away with the 
sponge closely applied, let it be lifted away, and the water allowed 
to fall from a distance. It is not, as a rule, at all necessary to 
permit the sponge to come directly in contact with a wound. Bodies 
which may not be washed away, no matter what their character, — 
(598) 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 599 

splinters, shot, balls, particles of powder, spiculae of bone, etc., — are 
to be removed with forceps, scoop, or other convenient means, the 
rule being to allow nothing to remain that may interfere with the 
process of repair. 

Hemorrhage. — A first matter to consider in hemorrhage is its 
character. Is it arterial, venous, or capillary? An arterial hemor- 
rhage is known by its scarlet color, and by issuing from the wound 
in jets. Hemorrhage from a vein is dark, and has a gradual and 
regular flow. Capillary hemorrhage is an oozing. Arterial hemor- 
rhage may require that the bleeding vessel shall be ligated. To do 
this, it is only necessary to sponge away the blood until the vessel 
can be plainly seen ; it is then to be taken hold of by the forceps, or 
caught in the tenaculum, and a strand of waxed silk thrown around 
it. In tying this silk, one must be careful that he shall not break 
his strand at either side of the knot ; also that the tightening shall 
be sufficient to cut the middle and inner coats. To prevent tearing 
the vessel from its bed by the breaking of the ligature, the rule of 
holding the thumbs upon the strands close to either side of the artery 
is always to be observed. 

After ligating a vessel, one end of the ligature may be cut off and 
the other brought out from between the edges of the wound ; this 
allows of an easy future removal of the knot. 

Torsion of a bleeding artery is a favorite mode of treatment with 
many surgeons. The end of the vessel is to be caught by the for- 
ceps and twisted. The author of the mode suggests that the torsion 
be continued until the end is twisted off. 

Acupressure is another and a very common method of treatment. 
A steel or gold needle is passed beneath the vessel in such manner 
as to tightly compress it against the neighboring parts. 

Pressure by pad and bandage, when a hemorrhage about the face 
will not yield to simpler means, is a very satisfactory way of treat- 
ment, and one entirely reliable. All the vessels of this region rest 
upon a bony floor, and all of them, at certain points, are sufficiently 
superficial for the purpose, — the facial, at the notch in the inferior 
maxillary, in front of its angle; the temporal, just in front of the 
ear above the zygomatic process ; the supraorbital, at the notch in 
the orbit ; the infraorbital, at the foramen below the border. 

A bandage of common application for any of these vessels is the 
crossed or knotted circular. A glance at the drawing (Fig. 229) 
will exhibit the manner of its employment. 

It is, however, very seldom that any of these operations are 




600 ORAL DISEASES AND SURGERY. 

necessary for the arrestation of hemorrhage about the face or mouth. 
Cold water thrown over the bleeding part from a sponge will fre- 
quently cause such a contraction, both of vessels and tissues, as to 
control it quickly enough. If water alone will not answer the pur- 
pose, let alum be added, as much as the water will dissolve. If even 
this should not answer the end, use a syringe, throwing a jet from 
Fig. 229.— Crossed or a distance directly upon the part bleeding ; 
Knotted Bandage. this last will seldom disappoint. Monsel's 
solutions, so warmly lauded for their styp- 
tic qualities, have exhibited to me more 
ill results than I have ever met with from 
any dozen other articles. If used at all, 
I think the bleeding points should be alone 
touched ; but of one thing any one using 
them may be assured : if the application 
does not control the hemorrhage instantly 
and permanently, he will have increased 
his trouble manifold. 
A hemorrhage that is venous or capillary will seldom require 
more than an application of cold water. If this or the alum-water 
should fail, astringent medicines may be administered internally. 
Of the anti-hemorrhagic medicaments, none has ever stood me in 
better purpose than a tincture of the Erigeron Canadense ; one drop 
to be given in a teaspoonful of water each minute. This dose seems 
like a very small one, but a larger administration has always ap- 
peared to me to do harm rather than good. Opium and lead I have 
used with much satisfaction, one grain of the former to two of the 
latter ; three or four of such pills may be administered at intervals 
of from one to two hours each, if found necessary. (See Hemor- 
rhage, p. 423.) 

SHOCK. 

Depression generally attends, to a greater or less extent, the recep- 
tion of all wounds. Surgeons divide shock into primary and sec- 
ondary, or that which is immediate upon the reception of the injury, 
and that which does not exhibit itself until some later period. Shock 
is prostration : this may be simply of a nervous nature, implying 
functional disturbance; or it may be organic, implying injury of 
some vital part; it may, again, have the twofold relation. 

In my own experience I have found few things more important to 
observe than the differences between real and apparent shock. One 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 601 

person, heavy and lymphatic in temperament, shall receive an in- 
jury mortal in its character, and yet, as the immediate or primary 
shock is concerned, afford less evidence of such injury than another 
of nervous temperament who may suddenly be called to look upon 
his wound. Mistakes, in such conditions, have very frequently re- 
sulted fatally to the persons most concerned. An article in the val- 
uable work* of Prof. H. H. Smith, of the University of Pennsyl- 
vania, so tersely considers this important matter that I am sure no 
language could give it better expression, f 

* Principles and Practice of Surgery, by Henry H. Smith, M.D., etc. 

f " In the normal or healthy condition of the body," says Professor Smith, 
"each function is so well and accurately performed as to pass unnoticed by 
an ordinary observer. The moment attention is called by marked inconve- 
nience, to any part, that moment its healthy action is changed, the duration 
of the disordered action varying greatly. When only interrupted for a lim- 
ited period, the function may be again performed without any appreciable 
alteration ; but when the interruption is of some hours' duration, the pre- 
servative action of life may be so impaired as to result more or less quickly 
in death. 

" When any injury of a part is of sufficient magnitude to produce a marked 
derangement in the function of the local nerves, reflex action may induce 
such a depression of the general powers of life as will result in the state tech- 
nically designated as Prostration or Collapse. This depressed condition is 
especially noticeable in the disturbance of the ganglionic system and its effects 
on the circulatory apparatus, and is shown either immediately or some hours 
or even days after the receipt of the injury. When apparent within a short 
time after the injury, the condition is designated as Immediate or Primary 
Shock; but when not developed until several hours or days subsequently, it is 
known as Insidious or Secondary Shock. In both there is a common feature 
of depression, the degree of which depends on the violence and extent of the 
injury, or the character and position of the part injured. 

" In the lighter forms of primary shock the patient trembles, is pale, faint, 
and with an anxious countenance ; and much the same symptoms are said by 
Longmore* ' to be witnessed in the horse, mortally hit, no less than in his 
rider ; the graver the injury, the graver and more persistent is the shock.' In 
marked cases the pulse is small and feeble or fluttering ; the respiration some- 
what oppressed and sighing ; the skin pale and moist, with cold perspiration; 
while nausea, vomiting, and hiccough are also seen, and in some cases there 
are often well-marked convulsions. The disorder of the nervous system varies 
greatly, and is sometimes rather the result of mental than of corporeal action, 
as in a pistol-shot in an extremity not involving important parts, but in which 
the patient's mind, having been impressed with the danger to which he was 
exposed, continues for some time subsequently to influence his corporeal func- 

* On Gunshot Wounds, Phila. edit., p. 45. 



602 ORAL DISEASES AND SURGERY. 

Yirus. — If a rabid dog, or other animal, bite the part we are con- 
sidering, or any part, — if a poisonous serpent strike its fang, or even 

tions. The violence of the symptoms of primary shock, in connection with 
moderate injuries, will depend often on the temperament of the patient, and 
his mental condition at the time. If excited by passion, quite severe injuries 
will often pass unnoticed, while in cool blood the very idea of a simple opera- 
tion will suffice, in some persons, to produce nervous prostration of a marked 
character, so much so as readily to induce syncope. In gunshot wounds of 
the lower extremities, and in severe railroad-injuries, and extensive burns, 
the symptoms of shock are usually most marked. In these cases the patient 
sometimes loses his consciousness entirely, and becomes faint, exhibiting great 
mental disquietude, with absence of thought, and giving foolish answers, or 
incoherent mutterings. The skin is covered by a cold sweat, and is pale and 
flabby ; the muscles are all relaxed ; the arm, if raised, drops as if paralyzed ; 
the sphincters of the bladder and anus permit the escape of urine and faeces, 
and of this the patient is unconscious. Kespiration is much disordered, and 
barely perceptible ; the pulse hardly to be felt ; the action of the heart feeble, 
or sometimes so faint as only to be heard by applying the ear to the chest ; 
the eyes have a vacant expression ; the eyelids when raised remain open from 
want of action in the orbicularis palpebrarum ; the jaw drops, and the hear- 
ing is temporarily lost, or is stimulated only by loud noises — the patient re- 
maining in this semi-dead condition for a period which varies greatly, as 
from a few minutes to hours, according to the extent of the shock. In the 
milder forms, with sufficient consciousness remaining, there is only a mental 
commotion, so as to permit easy reassurance ; but in the more marked degree 
this is often difficult, death sometimes supervening without reaction, though 
most frequently a certain amount of reaction is established and consciousness 
returns, or prostration again supervenes and the patient dies. When a limb 
is shot or torn away, or the body badly scalded, the local paralysis induced 
by the injury apparently prevents its immediate perception by the brain, and 
in numerous instances the patient has been ignorant of the loss of a limb until 
his attention was called to it. But as soon as the brain becomes cognizant of 
the injury, and the stage of depression or shock sets in, these apparently dis- 
tant local injuries are attended by the symptoms just enumerated, though 
they are seen less quickty than when the injury involves the trunk or head. 
When the symptoms of shock are marked, serious internal injury may be 
diagnosed even though not apparent at the moment. In most cases of marked 
shock the power of deglutition is more or less impaired for the time, while 
even in the milder instances the patient experiences such difficulty in swal- 
lowing as will cause, when the attempt is made, the sudden spasmodic effort 
designated as a 'gulp,' or the portion partially swallowed is ejected with 
symptoms of strangulation, often evidently of a hysterical character. When 
consciousness is not so much impaired, the patient may be able to control the 
pharyngeal muscles, yet those of the extremit' 5S will be so imperfectly regu- 
lated as to cause the limbs to tremble as if with fright, or as if exhausted by 
violent exercise. 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 603 

if the loose kiss of the ehancrous lip inoculate, — a first indication is 
to get clear of the poison. How? It is now very generally ac- 

" Duration. — The duration of the primary shock is very varied. In mild 
cases it disappears rapidly, the patient quickly recovering ; the depression 
or the disposition to syncope passing away and leaving him feeble in his cir- 
culation as well as in his general strength. But in more marked cases, as in 
the crushing of a limb by a railroad-train, or by machinery, or a round shot, 
the collapse lasts for several hours, when, the powers of life rallying, reaction 
occurs, and there is a renewal of the ordinary functions of the nervous 
system, noted in the circulation, which now tends to excessive action as much 
above the healthy standard as the depression was below it. 

"This reaction after the shock of injury, if not regulated by appropriate 
treatment, frequently creates a hyperemia or congestion of the blood-vessels, 
and soon develops inflammation and traumatic fever. To prevent this, and 
keep the reaction from exceeding its proper bounds, and yet raise the flagging 
powers of life, is the important indication to be accomplished in the treat- 
ment. 

" Treatment of Primary Shock. — In mild cases of shock, a few encour- 
aging words, a mouthful of water, or wine and water, with judicious expla- 
nations of the limited extent of the injury, will often suflice ; but in marked 
cases, when the patient's consciousness is impaired, and his powers of deglu- 
tition are temporarily paralyzed or much weakened, our means of reviving 
the action of the system must at first be limited to such remedies as can be ap- 
plied without being introduced into the mouth. The best plan of treatment 
is, therefore, to dash cold water on the head and face ; to excite artificial 
respiration by gently and quickly compressing the costal cartilages, or by the 
1 Eeady Method' of Marshall Hall ; by applying stimulating vapors, as strong 
ammonia, to the nostrils ; by exciting the nerves of the skin by sinapisms 
applied especially to the epigastric and cardiac regions, and to the extremi- 
ties; by applying heat to the surface of the body through hot bricks, bottles 
of hot water, etc., and by rousing the dormant action of the sympathetic 
nerves, through the bowels, by administering stimulating enemata, as oleum 
terebinthinse, infusion of capsicum, etc., sufficiently diluted with water or 
mucilage to prevent the development of rectal inflammation. About ^ij of 
ol. terebinthinse in a pint of soap-suds or salt water usually suffices. 

"When by the continued use of these remedies the patient regains suffi- 
cient consciousness to be able to swallow, or when the depression has not gone 
so far as that just alluded to, stimulants may be cautiously introduced into 
the stomach. Of these, such should be selected as are not likely to induce 
congestion of the cerebral vessels ; hence ten or fifteen drops of the aromatic 
spirits of ammonia in a little water, repeated every ten or twenty minutes, 
answers better than alcoholic liquors, unless the latter are given in moderate 
quantities, and their intoxicating tendency carefully guarded against. 

"As the pulse begins to respond to these measures, the use of both external 
and internal stimulants should be omitted, the natural tendency being to a 
reaction that must be restricted to proper limits. Should the pulse become 



604 ORAL DISEASES AND SURGERY. 

cepted that the immediate application of solid nitrate of silver to the 
parts wounded will neutralize these poisons, or that, at any rate, it 

full, hard, and frequent, so as to indicate febrile reaction, cold drinks, cold 
sponging, saline cathartics, and arterial sedatives, such as five drops of the 
tincture of veratrum viride every hour, may be necessary, — the powerful 
action of the latter remedy requiring its cautious administration, so as to 
repress but not depress too much the action of the circulation. The strong 
tincture of aconite root, in doses of two drops, or of tincture of digitalis, in the 
dose of ten drops every two hours, for a few hours, may also be advanta- 
geously used, if carefully watched and omitted as soon as the force and fre- 
quency of the pulse indicate their sedative action. By judicious attention to 
the proper action of the circulation in these cases, carefully stimulating the 
patient when in the collapsed or depressed condition, and inducing sedation 
when the reaction becomes excessive, patients may be rallied from the shock 
of injury and subsequently treated as demanded by the peculiar nature of the 
case. In that mild degree of shock, sometimes seen in patients who have 
been shot by a bullet in the extremities, or struck on the testicles or in the 
pit of the stomach, which is characterized by faintness, trembling, and men- 
tal anxiety, a little cold water, or wine and water, with a few words of hope 
as to the result of the injury, often suffices. 

" In many severe injuries, and especially in those which involve the main 
trunks of large nerves, or the spinal cord, or a great extent of the surface of 
the body, there is sometimes noted, at varying periods after the reception of 
the injury, a train of symptoms of a marked character, that are very justly 
spoken of as those of the secondary or insidious shock of injury. 

"Symptoms. — The symptoms of insidious shock are often so masked as to 
escape the attention of an inexperienced observer until they are so far devel- 
oped as to render it difficult to rally the forces of the patient. Thus, when a 
limb has been torn off by a cannon-ball, or in a rolling-mill or a thrashing- 
machine, or by a railroad-train, the patient not unfrequently appears to be 
almost unconscious of the severity of his injury, the local paralysis being so 
perfect as to prevent the excruciating suffering that such an injury would 
otherwise create. In the case of a railroad-accident, by the collision of 
opposing trains on one of our railroads, I saw a young man who had his arm 
cut off near the shoulder -joint, with so little suffering as to be unaware of the 
extent of the injury till his clothing was removed. By great care he subse- 
quently recovered. 

" In numerous instances in the experience of all surgeons, such patients 
have presented the following symptoms : immediately after the injury they 
are remarkably cool, self-possessed, and as if endowed with indomitable 
fortitude ; the pulse is often barely accelerated ; the respiration quiet and 
natural ; the skin pleasantly warm ; the mind clear, though perhaps a little 
torpid, but apparently with perfect consciousness. In some cases patients have 
been known to walk or ride some distance, evidently unconscious of injury, 
till suddenly faintness supervenes, and they fall to the ground, and die in the 
course of an hour, more or less. In other cases, where the external wound 






WOUNDS OF MOUTH AND ASSOCIATE PARTS. 605 

will so alter the condition of the wounded part as to slough off the 
offending agent and prevent its absorption. If an escharotic is not 

or injury is more evident, they will give directions for their removal, arrange 
their bed, business, etc., reply to questions rationally, and with great compo- 
sure ; yet, as has been well described by the late Dr. George McClellan,* 
they will present a countenance that is altogether unnatural, having 'an in- 
quiring, anxious look about the forehead, eyes, and upper portions of the face, 
while all about the mouth is smiling and composed.' In addition to which, 
' thej' look with a stare of alarm and suspicion at the surgeon when his atten- 
tion is called to them.' 

" After this period of treacherous calmness has existed from three to eighteen 
hours, the expression suddenly changes ; the lips become livid or deadly pale; 
the blood leaves the surface of the body ; the pulse flutters and becomes too 
rapid to count ; the respiration is short and panting ; a great sense of oppres- 
sion distresses the patient, and he sinks slowly, as if suffocated, or dies as if 
struck by lightning. In these cases the foundations of life are undermined, 
and the paralysis, which was at first limited to the part injured, suddenly 
extends to the nervous centres, and life is arrested by the want of proper 
nervous force. 

11 Prognosis. — The prognosis in cases of severe injury, in which the patient 
is thus unconscious of suffering, cannot be too guarded, the patient not being 
out of danger from insidious shock until after the lapse of forty-eight hours 
of perfect tranquillity. In the majority of such cases, when secondary shock 
supervenes, death ensues. 

" Treatment. — The treatment of secondary or insidious shock should be 
chiefly prophylactic, special attention being given to the preservation of the 
powers of the nervous system by the administration of food and stimulants, 
while all muscular action on the part of the patient should be carefully 
guarded against. 

" In many cases it will be useful to give milk-punch, beef-tea, quinine, car- 
bonate of ammonia, chalybeates, etc., as often as possible, until some evidence 
is shown of their effect upon the circulation. Then, while the patient is 
strictly confined to the recumbent position, stimulating frictions should be 
made along the spine, cold applied to the head if it becomes hot, pediluvia or 
hot bottles applied to the feet if cold, and access given to a sufficient amount 
of fresh air in the chamber to favor active respiration, while the patient is at 
the same time kept warmly covered up in bed. By such means the occurrence 
of secondary shock may be prevented ; but should it supervene, nothing but 
powerful stimulants to the spine, or the administration of ether, brandy, cap- 
sicum, etc., with the free use of beef-essence, affords a hope of checking the 
rapid prostration that, if not watched, will carry off the patient. In every 
case of serious laceration of a limb, opening a large joint, tearing nerves, etc., 
cautious watching of the pulse can alone guard against the development of 
insidious shock. If the patient is disposed to sleep, let the pulse be noted, and 

* Principles and Practice of Surgerjyp. IS. Phila., 1848. Edited by Dr. Jno. II. B. McClellan. 



606 ORAL DISEASES AND SURGERY. 

at hand (and this, at the moment, would be not unlikely), such a 
wound may be cut away. Suction is also an admirable prophylactic 
(not as the chancre inoculation is concerned : there would be here 
no immediate hurry) for most poisonous introductions. The danger 
to the person sucking such a wound would be very trifling; any 
danger at all depending on a casual abrasion that might at the 
time be present about the mouth or lips. Excision of bitten parts 
is frequently practiced. I recall an occasion, several years ago, 
where an enraged rattlesnake escaped from an experimenter, strik- 
ing its fangs into a colored assistant standing by. Without a 
moment's hesitation, the gentleman excised the part: no harm ever 
came of the matter. Tiding a patient over the depression of rattle- 
snake-poison by the stimulus and specific effects of whisky has 

let him be awakened every hour to take nourishment, if the pulse begins to 
flag. As the symptoms of shock are usually the result of serious and extended 
injury, the question of the propriety of operating for the relief of the injured 
part will often arise. Unless in the case of the laceration of blood-vessels 
from which the blood oozes, the opinion of most surgeons is adverse to the 
propriety of operating until reaction is fully established ; and since micon- 
sciousness can be readily induced by the use of anaesthetics, the supposed ad- 
vantages derivable from amputating a limb while the patient was unconscious 
of the injury are generally regarded as evidence of a want of judgment on 
the part of the operator. How soon after a reaction an amputation should be 
performed, will depend on circumstances, and be again alluded to when speak- 
ing of the advantages of primary over secondary amputations. 

" Occasionally it happens that, after reaction is established and traumatic 
fever supervenes, the patient becomes delirious, or traumatic delirium or 
wandering, without fever, is met with. If this delirium is an attendant on 
the febrile condition, sedatives, cooling applications, and the judicious use of 
opiates, with antiphlogistic remedies, as antimony, arterial sedatives, and 
such others as are adapted to inflammatory fever, will be required ; in other 
cases opiates are mainly sufficient. Should delirium tremens supervene, the 
usual treatment, as described in treatises on the practice of medicine, with 
great attention to the seat of injury, will be requisite. Among high livers or 
in the intemperate, a comparatively slight injury will often induce an attack 
of delirium tremens, requiring opiates and stimulants to counteract it, or, if 
the pulse is exceedingly frequent without prostration, the administration of 
large doses of the tincture of digitalis or veratrum viride. In delirium 
tremens supervening on pistol wounds, in many of our volunteer soldiers in 
camp for the first time and deprived of their habitual drams, I have seen 
marked benefit derived from the administration of half an ounce of the tinc- 
ture of digitalis every four hours until three doses are taken, this apparently 
heroic treatment sometimes inducing a perfect cure in thirty-six hours. As 
the dose advised is very large, the pulse should be cautiously watched before 
it is repeated." 



WOUNDS OF MOUTH AND ASSOCIATE PABTS. 607 

received so many confirmations as to have become a matter of 
common knowledge. In my own practice I have had on several 
occasions to excise poison wounds, and all have been successful. 
Without exception, however, the wounds excised had been received 
through some intervening substance, and such substances may have 
prevented the introduction of any poison. 

Healing Wounds. — Primary indications met, the second ques- 
tion is the healing of a wound. Every wound heals by granulation. 
The difference between a healing by first intention, as it is termed, 
and a healing by second intention is only a difference in degree. 
An incised wound, delicately and accurately approximated, heals 
with so little new inter-tissue that Mr. Paget mentions cases where 
no line of difference was discernible even under the microscope. A 
healing by second intention, so called, may require so much material 
to fill up a gap that the new or cicatricial tissue is observable at a 
great distance, as is frequently witnessed in scars from burns. An 
indication, then, of the utmost importance to be met in wounds 
about the face, is the avoidance of a necessity for new tissue. To 
accomplish this, every wound is to have its parts as nearly and as 
neatly approximated as possible, and the associated vascularity 
controlled. 

How wounds are best approximated is a matter which is always 
eliciting discussion. The common methods are by stitches, plasters, 
and compresses. An incised wound, of limited extent, about the 
cheek, seldom needs more than that a strip of adhesive plaster 
shall be thrown across it. If such a wound occupies the position of 
the lips, and shall have made a complete separation, adhesive plaster 
will not, perhaps, be found sufficient for the purpose. To insure the 
least scar, a stitch may be used to approximate the free edges, and 
increased support given by placing two lateral compresses at the 
sides of the wound, approximating these with a turn of the circular 
bandage ; or it may be found that, after the stitch, the adhesive 
strips will answer the purpose. Pins, with a figure-of-8 turn about 
them, make a very nice, reliable, and accurate adaptation, and, if not 
kept in too long, leave very little scar. 

A mode of approximation, which will be found very satisfactory, 
consists in using a suture of silver wire, and bringing the edges of 
the wound together, as directed in cleft palate. An objection, how- 
ever, it must be admitted, to all pins and stitches, lies in the fact of 
new wounds being made, — an irritation being begotten by the pres- 
ence of the foreign body, which is very apt to provoke more or less 



608 ORAL DISEASES AND SURGERY. 

suppuration, thus making other scars, as is witnessed so frequently 
in operations performed for bare-lip ; therefore it may be set forth as 
the best practice, that any means which breaks the flesh should be 
avoided, if any other may be made to answer. Silver or lead wire 
is preferred to the waxed silk only from the fact that these metallic 
agents seem to irritate less, and are, therefore, not so likely to make 
points of suppuration, and consequently scars. 

"When pins or stitches are used, they are to be left in place only so 
long as is absolutely necessary. This time will, of course, depend 
very much on circumstances. If an incised wound does as well as 
it may, twenty to seventy hours will usually be found sufficient for 
the union, while instances enough exist where, in this time, the pro- 
cess of repair seems scarcely to have commenced. A very good way 
to obtain information is to sponge off the wound, and to be instructed 
by the line of approximation: if this continues to show its incised 
nature, the pins are not to be disturbed ; if, on the contrary, it is a 
fleshy line of comparative solidity, the pins may be removed, — the 
parts will hold. 

The withdrawal of a pin or ligature is a matter demanding delicacy 
of manipulation. It is frequently, and indeed generally, the case, 
that more or less blood-rust collects upon a pin, making the removal 
a matter of such difficulty that, unless the precaution be taken to 
scrape away such rust before making the attempt, a disturbance 
of the cicatrix is almost inevitable. In the withdrawal of a pin, 
an important matter is the rotation of it ; such rotation facilitates 
the removal wonderfully. Metallic ligatures are generally disturb- 
ing ; the proper plan to take them away is to cut the wire at the 
side of the spot or knot opposite to that on which it seems desirable 
to withdraw it ; the end is then to be carefully straightened, so as 
to place it on a line with the part in the wound ; support is to be 
given the cicatrix by a finger applied on either side, when, with a 
rotatory movement, the wire is to be drawn away. In the use of 
the pin and figure-of-8, a very excellent plan is, on the removal of 
the pin, to allow the blood-matted silk to remain glued to the wound ; 
it serves to hold the parts together, and is entirely void of any 
offense as a source of irritation. 

When plasters are used, it is a necessity to have all hairs shaved 
away and the parts perfectly dry. The ordinary adhesive kept on 
sale by every druggist, composed of resin and lead plaster, is per- 
haps open to as little objection as any. It is to be applied in strips 
of convenient length and breadth, and rendered adhesive by holding, 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 609 

for a moment, the back of the strip over a vessel of hot water. There 
are skins, however, which this plaster irritates and inflames; w r hen 
cases of the kind are encountered, it is well to employ the isinglass 
plaster. An objection to this plaster is its tendency to curl and 
roll up. It is applied by moistening the glazed surface with water. 

In the use of plasters, it is a good rule to allow a space between 
each strip : this not only keeps the wound exposed to observation, 
but permits of easy drainage. The only exception to this rule is 
found in small cuts where it is thought desirable to use collodion. 
This mixture of gun-cotton and ether is applied either directly over 
a cut — first nicely approximating the edges, and holding the parts 
together until the ether has evaporated — or indirectly through the 
agency of saturated slips of gauze or other convenient material. 

The removal of a plaster is to be effected by drawing the strip 
from either side toward the wound ; such a removal being accom- 
plished without any strain upon the cicatrix, the line of union being, 
of course, supported by the thumb and forefinger of the other hand. 
If a wound seems to be doing well under plaster, there need be no 
special haste in its removal. It is usually the case, however, that 
such a dressing will not continue to do service longer than two or 
three days. In simple incised injuries, this is generally all that is 
required, but in lacerated wounds, dressings are demanded an in- 
definite length of time, and require continued renewal. In reapply- 
ing a dressing of adhesive strips, a good plan is to displace and 
replace one at a time. 

Complicated Wounds. — The history of a few cases may, perhaps, 
best serve to illustrate practice in this direction. 

Case I. — Little girl, of remarkably perfect temperament, — tem- 
peramentless, it might be said, — about four years of age, brought 
into the office with quite a gash in the lower lip, and the six anterior 
teeth knocked directly back: considerable hemorrhage. 

Treatment. — Checked the hemorrhage, and cleaned the parts by 
the free use of cold water applied through the syringe ; pushed the 
teeth back into their unfractured alveoli, and retained them in place 
by laying a delicate roller over them, fixing it beneath the chin.. A 
single stitch of waxed silk was placed in the wound of the lip. The 
case was dismissed for the day, with directions to keep the parts 
refrigerated through a continuous application of cold water. 

Second day. Same treatment continued, the band over the teeth 
being replaced by a fresh one. 

Third day. Wound in the lip healed sufficiently to remove the 

39 



610 ORAL DISEASES AND SURGERY. 

ligature. Teeth somewhat tightened ; very little inflammation ; 
continued the bandage, but left off the application of the water. 

Fourth day. Removed the bandage. Teeth very sore, but doing 
well, and quite fast. 

Eighth day. Patient dismissed : some soreness still in the teeth, 
but needing only time to bring them to full health. 

This case was seen three months after the accident ; there was no 
discoloration of the teeth, and not the slightest evidence that any 
harm had been done them. 

Case II. — Child six years of age. Four front inferior teeth 
knocked loose by a blow from a ball ; some contusion of th'e lip, but 
no break in the continuity; very little bleeding. 

Treatment. — Removed the injured teeth ; absorption having pro- 
gressed to a considerable extent, applied to the lips dressing of cold 
water ; case well enough to dismiss next day. 

Case III. — Little boy, five years of age, fell upon a curbstone, 
fracturing the superior alveolar process. Examination revealed six 
teeth movable in mass, the fracture extending from tuberosity of 
right side to canine fossa of left. The accident occurred nine hours 
before recourse to treatment. 

Condition. — Child feverish and restless; pulse much excited; 
soft parts about the seat of fracture considerably swollen, and so 
tender as to cause the little patient to scream when the parts were 
touched. 

Treatment. — A Seidlitz powder; hot pediluvia; the mouth 
syringed with cold water ; iced lemonade ad lib.; spts. Mindereri, 
5U> T6 S r - acetate of morphia. This was the treatment on the after- 
noon and night of accident. 

Second day. Hot pediluvia; iced lemonade, made of crushed ice; 
mustard poultice at back of neck. 

Third day. Swelling of gums very much abated. Fed the child 
freely with spoon food, then brought the fractured part to its place 
by reducing to proper articulation with lower teeth, and retaining in 
position by means of the yard strip modification of the Barton band- 
age ; a fairly comfortable day was passed. In the evening the band- 
age was loosened, the child again fed, the bandage tightened, patient 
put to bed ; a comfortable night was passed. 

Fourth day. Doing very well. On loosening the bandage there 
was very little tendency in the fractured part to move of itself; child 
fed with soup food ; mouth well syringed with cold water ; bandage 
reapplied. Patient played about the room most of the day, taking 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 611 

lemonade and rice-gruel very frequently, by placing the fluid within 
the lips and sucking it between the teeth. 

From fifth to tenth day did little more than continue the treatment 
of the fourth. 

Eleventh day. Removed the bandage. Fracture fairly solid ; able 
to hold of itself; liquid food continued; no other treatment. 

Fifteenth day. Patient began to eat solid food ; passing on, with- 
out further treatment, to a good cure. 

Case IV. — Little girl, three years of age, markedly scrofulous; 
lip cut through ; fracture of process of central, lateral incisor, and 
cuspid teeth of left side inferior maxilla; cutting edges of teeth 
thrown backward. 

Treatment. — The wound in the lip being quite extensive, a hare- 
lip pin was inserted, and the parts pushed together and held with a 
figure-of-8. The fractured process was restored to position, and 
retained by tying the one end of a strand of waxed floss silk around 
the last molar tooth of the injured side, bringing it forward, passing 
it between the first molar and cuspis of the fractured part, back of 
the three teeth of the broken process, then out between the. central 
incisors, and back to the first molar, where it was tied. This liga- 
ture supported the part in its place very well. The ferrated elixir 
of bark, in doses of twenty-five drops, directed three times a day. 

Second day. Wound in the lip doing tolerably well ; seat of frac- 
ture looking puffy and asthenic. Very weak solution of compound 
tincture of capsicum ordered to be thrown, ter die, over the part. 

Third day. Looking worse ; ligatures cutting into the gums ; 
patient refusing solid or soft food ; took away the ligature ; tempted 
the appetite with ice-cream and jellies; scarified the puffy gum. 

Fourth day. Matter oozing from about seat of fracture ; etherized 
the child ; dissected down to the fractured piece, and removed it. 

Sixth day. Very much improved ; wound healing fairly ; con- 
tinued to syringe with the dilute capsicum comp. 

Eighth day. Case well enough to be dismissed. The pin in the lip 
had been removed on the third day. The wound gaped some little ; 
but the removal was a necessity, on account of irritation produced 
by its presence ; support was given by an adhesive strip, after the 
taking away of the pin, and the part stimulated with capsicum, 
under which it healed very rapidly. 

Case V. — M. L., an iceman, aged perhaps thirty-five, brought into 
the office immediately after having been kicked on the mouth by a 
vicious mule. Patient very pale and faint. Examination revealed 



612 ORAL DISEASES AND SURGERY. 

comminuted fractures of the alveolar process of both jaws, with the 
teeth knocked into every position. 

Treatment. — First, stimulation with a little brandy. The patient 
revived. Incisions on either side of the teeth were made down to 
the bone, and some eight pieces removed, with the teeth associated. 
No hemorrhage of consequence attended the operation, and in the 
course of three or four days the man was going about his business, 
— no treatment, outside of the free use of cold water, having been 
indicated or employed. 

Case VI. — C. H., struck over the angle of the jaw by a minie- 
ball, which plowed across the face, completely dividing the cheek, 
and grooving the right nasal ala. A first treatment employed on 
the field, where the injury was received, consisted in associating the 
severed parts with a series of interrupted sutures, and the application 
of a poorly adapted bandage. In this condition the patient was sent 
several days' journey, to a hospital in which I happened at the time 
to be employed. My first observation of the case exhibited an im- 
mense wound, stitches all torn out ; superior maxillary bone exposed, 
with groove cut into it ; suppuration most profuse ; patient ex- 
hausted, irritable, and feverish. 

Treatment. — The weather being oppressively hot, a large basin of 
water was brought, in which the head and face were thoroughly, yet 
tenderly, washed. The matted hair was combed out and arranged. 
This refreshed him very much. Examination of the wound was 
commenced. On the groove in the bone was found no splinter, nor 
other indication adverse to the direct and immediate overlying of 
it by the soft parts. Attention to the line of wound in the soft part 
exhibited that the slough, which must necessarily have ensued from 
the passage of the ball, had been completed, and that a process of 
repair was attempting to inaugurate itself. Indications thus being 
rendered very plain, the whole of the cut and suppurating surface 
was slightly stimulated by an application of dilute tincture of iodine, 
and then carefully moulded into place and approximated. The main- 
tenance of this apposition was accomplished by fitting a compress to 
the cheek, and also below the wound, and with a bandage, carefully 
lifting and supporting it; no stitches, pins, or plasters being em- 
ployed. The success was perfect, the whole line of the wound being 
exposed, permitting the fullest and most frequent examination. In 
ten weeks the parts had united so firmly as to allow of the removal 
of the compress and bandage. The only medication employed con- 
sisted in the administration of an occasional Seidlitz powder, and a 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 613 

daily glass of porter, with repeated applications to the wound of the 
dilute iodine, one part of the officinal tincture to four parts water. 

Case VII. — Little girl fell over the shafts of a wagon, cutting, in 
some unappreciated way, her tongue directly in twain, for the dis- 
tance of an inch down the middle. Hemorrhage was very profuse, 
requiring the ligature of a vessel. This wound was united by two 
stitches of the interrupted suture passed deep in the substance of 
the organ ; cold water directed to be held in the mouth quite continu- 
ously, for the first day ; patient fed on ice-cream and jelly. Third day, 
stitches removed, union complete, ligature loosened, and was pulled 
away on the seventh day. 

Case VIII. — Brigadier-General D., standing upon an outlook, was 
struck by a sharpshooter, the ball passing through the right ramus 
of the lower jaw, shattering the bone, passing forward across and 
through the tongue, emerging from and splintering the body of the 
bone on the left side. The treatment pursued upon the field had 
been to check an alarming hemorrhage from the region of entrance 
of the ball, by stuffing the wound with charpie saturated with 
Monsel's solution of iron, throwing a bandage over it, and hurrying 
the patient to the hospital. 

Condition on entrance. — Patient arrived, and was put under my 
care about eleven o'clock at night; complained, by writing on a slate, 
of great thirst, with entire inability to swallow, and of the painful 
effort it required to breathe ; had not been able to drink since the 
accident, which happened two days before. 

Treatment. — Examination revealed marked displacement of the 
middle piece of the fractured bone. This, with the tongue being 
pulled backward by the hyoid attachment of the genio-hyoglossal 
muscles, sufficed to explain part of the difficulty in respiration and 
deglutition. The tongue itself, however, was much swollen, and 
had a ball wound through its base. Two primary indications thus 
presented : to keep the body of the bone and tongue in position, and 
to reduce the swelling in the tongue. The external wounds were 
for secondary consideration : the patient had to breathe and had to 
be nourished. The mouth was first well syringed with cold water, 
which was found most refreshing ; the bone was then brought 
forward, the inferior teeth in front of the superior ; the jaws were 
closed, and held together by a delicate bandage, the middle fragment 
being thus retained even in front of its natural position, and pulling 
the tongue forward with it. This accomplished, the patient was 
propped up in an arm-chair, and his feet immersed in hot water, the 



614 ORAL DISEASES AND SURGERY. 

application being continued until every vein and capillary was en- 
gorged. A local abstraction of blood was not thought desirable, as 
he had already lost as much as he could well spare. The result 
of such a primary treatment was, that in half an hour the patient 
was able to swallow spoonfuls of lemonade. This drink, cold as it 
could be made, was continued during most of the night, serving by 
its refreshment to give much comfort, and by its refrigeration to 
abate the vascular excitement. About four o'clock in the morning 
the patient fell into a disturbed sleep, which continued until eight. 
At nine o'clock the tongue was examined by separating the lips and 
looking at it through spaces which existed between the teeth ; the 
swelling and turgidity had very much diminished. The feet were 
again placed in hot water, and the blood held in the parts until a 
sense of faintness was experienced. This gave increased relief. The 
patient thus being over the immediate danger, attention was directed 
to the state of the external injuries, and the line of passage of the ball. 

The wound at the external angle of the jaw was found to occupy 
quite a space in the parotid fossa, the ball having evidently been 
received as the general had turned his head to address some one 
behind him. It was stuffed with charpie, looking now a black and 
blood-infiltrated mass, and which evidently had been thrust hard and 
solidly into the wound, and now had swelled to double its former size, 
displacing the parts to a very marked extent. This plug being found 
firmly fixed, it was left to be removed or not, as circumstances should 
seem to direct, at a future time. The wound of exit was larger than 
might have been expected, spiculae of bone having considerably torn 
the parts ; from it were removed several small splinters. The probe, 
passed into this opening, revealed the line of the wound running 
through the base of the tongue obliquely across the mouth. The 
treatment consisted in the free use of permanganate of potash and 
water. The patient passed the day in a fair degree of comfort. 

A sudden secondary hemorrhage being the next thing to fear, it 
was determined on the third day to remove the plug ; this was ac- 
complished only after a full hour of labor, the charpie having wedged 
itself into every imaginable space, the removal being effected by the 
very free use of milk-warm water and the most gentle of traction 
with the forceps and scalpel handle. The removal was attended with 
considerable pain, but without the loss of a single drop of blood. 
The relief from the sense of pressure afforded was so very great as 
to change the whole appearance of the patient, he now breathing 
and taking his beef-essence with the greatest freedom. The appear- 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 615 

ance of the wound was really very promising, attempts at granula- 
tion being quite evident, while nothing especially threatening was 
to be observed. The day after this dressing, the patient, in opposi- 
tion to all advice or commands, insisted on being passed to his family 
in Washington. All the dangers of secondary hemorrhage were 
exposed and explained to him, but he seemed to be possessed of the 
single idea of getting to his home. At five o'clock in the afternoon 
he was driven to the steamer plying between Fortress Monroe and 
Baltimore, continued in charge of a surgeon who had been sent with 
him from the field. At midnight, while on the Chesapeake, the most 
profuse secondary hemorrhage came on, which was controlled, as 
best it might be, by masses of ice held continuously to the wound. 
The patient died during the next day at a hospital on the wharf in 
Baltimore, under what exact circumstances I could not learn ; most 
likely, however, from exhaustion. 

Case IX. — J. B., middle-aged man, gash, from a blow, lacerating 
the cheek, opening the duct of Steno. 

Treatment. — With a heavy-eyed needle, carried a loop from the 
bottom of the wound to the inside of the cheek: the silk, which 
was very loose, conducted the saliva into the mouth. Brought the 
external wound together by strips of resin plaster ; no other treat- 
ment required, save an occasional dressing. In a week the loop 
had sloughed through into the mouth, preserving completely the 
track for the secretion, and the process of granulation had ad- 
vanced almost to the stage of cure in the external wound. No after- 
trouble. 

Case X. — C. A., young gentleman, twenty years of age, deep 
punctured cut in the floor of the mouth just to left of middle line, 
made by the slipping of an elevator in the attempt to remove root 
of upper canine tooth. No hemorrhage, or immediate bad sign of any 
kind ; patient very much frightened. Accident had occurred two 
days before my seeing the case ; part very sore and tender ; inflam- 
mation limited. 

Treatment. — Directed arnica-water for relief of the soreness ; 
nothing else indicated or required ; the wound healing rapidly and 
kindly. 

Case XI. — Cut received by young lady, exposing and incising 
mylo-hyoid artery of left side in the groove; hemorrhage very great 
and persistent. 

Treatment. — Upright position; tinct. Erigeron as directed; strong- 
alum solution held to the part on tufts of cotton, afterward thrown 



616 ORAL DISEASES AND SURGERY. 

with the syringe ; ice to the part, etc. No result on the bleeding. 
The patient becoming affected from loss of blood, enlarged the 
wound, picked out the vessel with the Liston forceps, and tied it. 
This, of course, controlled the hemorrhage. Patient recovered. 

Case XII. — Mr. C. Performed operation on the cheek for a pecu- 
liar erectile growth ; cut well into the sub-tissue, making quite a 
deep wound, just as if the part had been scooped out. 

Treatment. — Cold-water dressing ; waiting on nature to fill up 
wound with granulations; nothing else required, nothing done; the 
case progressed to a satisfactory cure, excepting a raised scar. 

Case XIII. — Young man, shot through the cheek ; the mouth 
being, at the time, fortunately open, the ball passed out, doing no 
further damage; no hemorrhage. 

Treatment. — Applied cloths wrung out of cold water, for the pur- 
pose of controlling vascular reaction ; nothing else done ; wound 
suppurated until the compressed and devitalized tissues were 
sloughed ; then kindly granulated, the patient being entirely well 
in a month. 

Case XIY. — Patient, young lady. In an attempt to extract the 
first molar tooth of right upper jaw, a flap of gum had been torn, 
extending around the mouth to the left second bicuspid ; this flap 
had been hanging loose some three hours before the patient pre- 
sented herself. 

Treatment. — Cut it off, and depended on granulations from the 
wounded surface for the filling up ; patient comfortable next 
day; entirely well in a week; no other treatment of any kind re- 
quired. 

Case, XV. — Boy, twelve years of age ; playing with powder con- 
tained in a bottle, it unfortunately exploded, throwing the glass and 
powder into his face. When first seen, an hour after the accident, 
the patient was in the greatest distress ; the eyes were completely 
closed, lashes entirely destroyed, hair singed, face raw and bleeding, 
pulse rapid, and very irritable. 

Treatment. — First, Seidlitz powder, with half-grain of opium ; 
second, removal of such pieces of glass as could be readily picked 
away with the forceps; third, cold-water dressing. In an hour 
the patient was fairly comfortable ; at the end of which time a second 
half-grain of opium was administered. 

Second day. Face very sore, but no burning pain ; picked away 
several small pieces of glass and a number of powder-grains. Con- 
tinued cold-water dressing. 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 617 

Third day. Reactive inflammation evidently aborted ; water 
dressings dispensed with; used in place 

R.— Olei lini, 

Aquae calcis, aa q. s. 

With this the surface was protected from the atmosphere until it 
cicatrized,— a period of two weeks. During the time of cure some 
little attention was given to the diet, the patient for the first day 
craving principally ice-cream, which answered very well, and served 
to allay a slight tendency to irritative fever which existed; the 
latter four days of the first week stimulating articles of food were 
interdicted ; after this he ate what he best liked. 

Case XVI. — Patient, young gentleman. Struck, w T hile on a 
gunning excursion, by a buckshot, which passed through the lower 
lip, burying itself in the bone. Patient not seen until the next day; 
lip too much swollen to permit of examination. 

Treatment. — Cold-water dressing to the lip. Mag. sulph. ^ss 
internally. 

Third day. No diminution in swelling; slight erysipelatous 
blush; brushed the parts with the following combination: 

R. — Tincturae ferri chloridi, £ij ; 
Quiniae sulphatis, gr. xxx ; 
Tincturae cinchonas, ^j. M. 

In one hour the blush disappeared. 

Fourth day. Inflammation, with the swelling, disappearing very 
rapidly. 

Sixth day. Probed the wound ; discovered the shot lying near the 
root of the first bicuspid tooth ; dissected away the gum from the 
inside, and with a very small curved gouge picked the lead away. 

Seventh day. Inflammation back again, confined, however, rather 
to the inside of the mouth ; reapplied the cold-water dressing, and 
directed a Seidlitz powder. 

Eighth day. Better ; inflammation rapidly yielding ; a little pus 
escaping from the shot track in the bone. 

Tenth to thirteenth day. Track of wound in the bone suppu- 
rating considerably ; tinct. iodine injected. 

Fourteenth day. Discharge diminishing ; iodine still continued. 

Sixteenth day. Discharge entirely ceased ; patient dismissed. 

Case XVII. — Patrick T., laborer. While engaged in blasting 






618 ORAL DISEASES AND SURGERY. 

rocks, the patient was struck with great force, just below the orbit, 
by a flying fragment, lacerating, in a frightful manner, the soft parts 
of the face, breaking and knocking into the naris the left nasal bone, 
and severely concussing the maxillary. No hemorrhage ; heavy 
shock. 

Treatment. — The patient being a strong, plethoric man, reaction 
was allowed to establish itself, which it did completely only after 
the lapse of several hours. Cold-water dressings were, however, 
at once applied to the parts, every deduction being in favor of the 
inference of severe inflammation. The accident occurred in the 
morning. At seven in the evening, a pine stick, whittled, to make 
its introduction easy, was coated over the end by dipping it in 
melted wax, and with this, insinuated into the nostril beneath 
the depressed nasal bone, it was thrust out into place, position 
being maintained by a tuft of wax-coated cotton, having attached 
to it a string for its withdrawal, being pushed up beneath the 
fracture. 

Examination of the injured face and maxillary bone revealed con- 
tusion and injury to such an extent as to make it evident that the 
process of cure must be that of exfoliation, sloughing, and repair 
by granulation ; the only treatment was then the expectant, and 
this was met by a simple water dressing. 

Second day. Most decided reaction. Mag. sulph. ^ss adminis- 
tered in half a glass of water ; water dressing, medicated with lead 
and laudanum. 

R. — Plumbi acetatis, 3U ; 
TincturaB opii, ^ij ; 
Aquae, |xxx. M. 

Cloths wet with this lotion kept constantly upon the cheek. 

Tliird day. Inflammation abating, but patient complaining of 
feeling hot and generally miserable. Lemonade ordered as a febri- 
fuge, to be made by expressing the juice of an ordinary lemon into 
a goblet, sweetening, and filling up the glass with ice broken into a 
coarse powder. To be allowed ad libitum. . 

Fifth day. Wound suppurating; fever all gone ; dressing changed 
to simple water ; waxed cotton changed in nostril, — the replacement 
giving much pain. 

From fifth to tenth day. Water dressing continued ; portion of 
external plate of the bone apparently dying ; periosteum evidently 
destroyed. 



WOUNDS OF MOUTH AND ASSOCIATE PARTS. 619 

Eleventh day. Stimulation commenced ; parts wet three or four 
times a day with the following: 

R. — Aluminis pulveris, 3'j ; 

Tincturas capsici composite, ^ss ; 
Aqua3, ^xvj. M. 

Fifteenth day. Granulations being thrown out from around the 
edges of the wound ; parts brought as closely together as possible, 
and retained with adhesive strips ; nasal fracture doing very well. 

Twenty-fifth day. Wound of face entirely healed, with the ex- 
ception of a small place in the centre, which, when examined with 
the probe, discovered a sinus leading to diseased bone. 

Thirty-fourth day. Piece of bone presenting at the sinus ; en- 
larged the opening, and withdrew a sequestrum rather larger than an 
ordinary finger-nail. Examination with the probe, after the removal, 
gave the fleshy feel indicative of repair. Case dismissed on the 
thirty-sixth day. 

Case XYIII. — Young man, struck on the side of the face, in a 
street-brawl, with a slung-shot; face severely cut and contused; 
outer boundary of the antrum driven backward into the cavity, not 
fractured apparently, but simply bent inward. 

Treatment. — Cold-water dressing, — no other application for the 
first three days. After this, the patient being compelled to go out 
to his work, adhesive strips were employed; repair progressed 
rapidly, without a single adverse manifestation. The depressed 
plate of the sinus gave no trouble, soon accommodating itself to its 
new position ; all sense of soreness leaving it by the end of the 
second week. External wound cicatrized in twenty days. 

Case XIX. — A young man slipped while standing on a stall in a 
market-house ; falling forward and downward upon one of the hooks, 
it entered his mouth, breaking off three of his upper teeth, perfo- 
rated his hard palate, and passed by its point into the right nostril. 

Treatment. — Seen first one hour after the accident. Pain in the 
broken teeth unbearably severe. Examination discovered the en- 
gorged pulps entirely uncapped and bulging from their cavities. 
The probe introduced through the wound in the palate passed readily 
into the nares, giving little or no pain. No fracture of the bone, 
save a few trifling spiculae about the circumference of the puncture. 
The roots of the broken teeth were at once extracted, and the case, 
for the time, left to nature. 



620 ORAL DISEASES AND SURGERY. 

Second day. No necessity for any interference ; some soreness, 
but no actual pain. 

Third day. Nothing required to be done. 

Fourth day. Three trifling pieces of bone discharged into the 
mouth. 

Seventh day. Wound granulating very satisfactorily. 

Fifteenth day. Nature unable, evidently, to quite fill up the open- 
ing; assisted by scarifying the circumference of the wound, and 
touching with tincture of iodine. 

Seventeenth, twentieth, and twenty-second days. Scarified, and 
touched with iodine. 

Twenty-fourth day. Opening completely closed. Case dismissed. 

Case XX. — Gentleman. While striking the iron handle of a chisel 
in the act of opening a box, a small piece flew off from the hammer, 
burying itself in the malar process of superior maxillary bone. 

Treatment. — With probe, searched in the wound for the foreign 
body; found it in position as described, with very oblique track 
through soft parts. Introduced a sharp steel instrument, and, after 
some trouble, succeeded in working the piece loose; could not, how- 
ever, get hold of it with forceps without such manipulation as would 
evidently enough contuse the parts. Introduced a director down to 
the body, and cut to it; removed it in this way without effort. 
Wound closed with two delicate sutures, and the cold-water dress- 
ing applied ; in three or four days the parts were entirely well, with- 
out the slightest suppuration having occurred, — no noticeable scar 
being left. 

Case XXI. — A little boy, Harry H., while playing with a wooden 
paddle which had been made for use in rendering lard, slipped, 
while having one end of it in the mouth, the weight of his body 
carrying the stick through the soft palate, making a complete 
separation between the veil and hard parts. This patient was first 
seen three days after the injury. No inflammation of consequence 
existing. 

Treatment. — Etherizing the patient, the parts were stitched to- 
gether with interrupted sutures of silver wire, the approximation 
being maintained by perforated shots clamped over the wire. Only 
a very limited union, however, was secured, the two most important 
stitches sloughing out. On the fourth day from the introduction of 
the first stitches, those which had been lost were replaced, which 
last, by the eighth day, also sloughed out, yielding no increase in 
extent of the union, but happily being associated with such extent 



WO VXDS OF MOUTH AND ASSOCIATE PARTS. 621 

of granular face to the wound that, when the veil was pressed up- 
ward, it met the part from which it had been torn. An impression 
of the mouth was now taken in very soft wax. From this a model 
was secured, to which model was struck a silver plate. This plate 
enveloped the back teeth of the upper jaw, but was cut to fit the 
palatine faces of the anterior. Impressions were next taken of the 
inferior teeth, and caps made to fit the molars. Putting next the 
plate and caps in place, they were attached by means of wax, and 
the apparatus thus associated lifted carefully from the mouth, the 
piece being completed by soldering the parts together. Thus pre- 
pared, the apparatus was put in the mouth, and the two jaws held 
in place by means of the Garretson bandage. In two weeks union 
was sufficiently firm to permit the removal of the splint. 

Case XXII. — Stout Irish lad, twelve years of age, shot in the 
face by a playmate. In this case the pistol was in the hands of a 
smaller boy, the muzzle being directed obliquely upward. The ball, 
which was a good-sized minie, struck the centre of the nose, and, 
as it passed upward on the line of its projection, was deflected at an 
angle of about eighty degrees, by an influence exerted by the nasal 
bones, against which it struck. This boy was first seen on the 
second day after the accident. No inflammation, no evidence of 
shock, indeed, no anything that would lead to the inference of an 
accident of gravity ; even the wound of entrance was scabbed over, 
and looked like any insignificant sore. 

Treatment. — Breaking away the scab, search was made for the 
course of the ball by means of the ordinary silver probe. As the 
instrument reached the nasal bones, the condition of reflection was 
recognized. Examining next the mouth of the patient, a solid pro- 
jection was observed at the line of union of the palatine plates of 
the maxilla and palate bones. Inferring this to be the ball, an in- 
cision was made through the soft parts; this exposed, however, not 
the ball, but a fractured portion of bone. Removing this, the ball, 
much flattened, was found immediately above it, being wedged in 
the site from which it had forced the bone. The boy seemed to re- 
quire no treatment, and therefore received none. In no way had he 
a bad symptom. 

Case XXIII. — Michael M., car-driver. Separation from its max- 
illary attachment of left nasal bone. Deformity very marked; the 
whole nose looking as if it had been thrust upon one side of the face. 

Treatment. — The parts being very much inflamed, application of 
the lotion of lead-water and laudanum was ordered, and continued 



622 ORAL DISEASES AND SURGEBY. 

until the condition was fall y combated ; two days being required 
to secure such a desired result. Using now the handle of an ordi- 
nary scalpel, the displaced bone was lifted into position, and was 
retained by making a flattened roll of the common adhesive plaster, 
— the unspread side out ; this, being dipped in olive oil, was directed 
into place, and retained for a week by a ligature, which kept it well 
in position by passing over each ear. At the end of this period the 
roll was withdrawn and the parts left to nature. A perfect cure 
resulted. 

Case XXIV. — From Langenbeck. Head of patient was caught 
between a locomotive and its tender. The eyelids were torn away 
from the orbit, and a deep wound ran down from the inner canthus 
to the upper lip. A probe could be passed into the antrum: not a 
trace of the eyeball could be found; while in the orbit was a bluish- 
black pulsating mass. The nasal bones comminuted. Patient con- 
scious, but sleepy ; pulse slow ; violent pain on right side of head. 
A week afterward, as head symptoms disappeared, and the extrava- 
sated blood had been somewhat absorbed, a closer scrutiny could 
be made. The eyeball was discovered to have escaped into the 
antrum from the orbit by a hole in the orbital margin of the upper 
jaw, big enough to admit the finger easily, — the axis of the eye 
standing vertical, the cornea downward. 

The fragments of bone were adjusted as well as possible, and the 
eyeball replaced in the orbit. It was uninjured, and vision was 
perfect. 

About ten weeks after, by two blepharoplastic operations, the 
eyelids were brought into tolerably good condition. They could be 
closed, and usually so remained, but could be opened enough to ex- 
pose the cornea and permit sight. The globe was, however, per- 
fectly immovable. About five months after the injury, ulceration 
and suppuration of the cornea occurred, and the globe atrophied. 



CHAPTER XXX. 

FRACTURES OF THE MAXILLARY BONES. 

Fractures of the maxillary bones may be divided into two classes, 
simple and complicated. The first applies to such cases as are with- 
out external or associate injury, implying a simple break in the con- 
tinuity of the bone. The second applies to cases associated with 
comminution of the bone, to external lesions, injury to vessels, to 
teeth, — in short, any condition which alters the fracture from one 
of a simple to one of a compound character. 

The inferior maxilla, from the exposure of its position, from its 
shape, and from its office, is much more liable to the accident of 
fracture than the superior, — the accident being commonly the result 
of blows, falls, kicks, etc. These fractures will, in the majority of 
cases, outside of gunshot injuries, be found associated with the 
body of the bone, the rami escaping, from the fact that a force 
brought to bear upon them slips the articulation more easily than 
it may break the bone. 

The weakest part of a bone would most naturally be the part to 
yield in a diffused blow. In most inferior maxillae this weakest 
point is found to be the line of the roots of the canine teeth ; hence 
the most frequent seat of fracture in the bone is in this line, either 
to the right or left, as influenced by the direction of the force. This, 
however, as would be inferred, applies to an unbroken dental arch : 
when teeth have been lost, and the process removed, the situation 
of this weakest part is materially altered. In gunshot injuries, acci- 
dents from the passage of a wheel over the jaw, or similar applica- 
tions of force, fractures occur, of course, at the seat of such appli- 
cations, and follow no rule. In the work of Prof. Hamilton on 
Fractures, in twenty-four recorded cases of breaks in the inferior 
maxillary bone, one was perpendicular through the symphysis, twelve 
were through the body, five through the angle. Of the twenty-four, 
eleven were of a double or triple character, the direction of the frac- 
ture being mostly oblique, both as direction and the face of the break 
are concerned. 

(623) 



624 ORAL DISEASES AND SURGERY. 

It is singularly the case that most fractures of the body of the 
lower jaw are compound, the opening existing on the lingual aspect : 
this seems to be the result of the easy lacerability of the gum tissue, 
combined with the quick displacement inward of the fractured part. 
This exposure of the bone seems, in many mouths, to be of no very 
material consequence. In others, however, it is quite the reverse, 
the saliva thus allowed to come in contact with the bone degener- 
ating and deteriorating the tissue. 

Fractures from blows of the fist, or similar concentrated forces, are 
apt to be single ; from falls, they are apt to be multiple ; from kicks 
of animals, comminuted. A common cause of fracture, familiar to 
every dentist, is found in the extraction of teeth having large and 
bifurcating roots : luckily, however, such fractures are not of a seri- 
ous nature, generally being confined to the alveolar process, although 
cases are on record where such accidents have been so extensive and 
severe as to cost the life of the patient. Complete division in the 
continuity is, however, rare, very few cases having occurred. 

The symptoms denotive of a fracture are seldom or never obscure. 
There are, first, the mobility at the break, and the crepitation ; second, 
when the break exists in the body, there is the loss of harmony in the 
line of the teeth, the short fragment being pulled upward. If the 
fracture be multiple, irregularities will be produced in the line of the 
arch, and in the articulation. If the freed portion be the anterior or 
chin part, it will be dragged downward and backward by the action 
of the genio-hyoid, hyoglossus, and digastric muscles. If it be at the 
line of the cuspid tooth and at the upper portion of the ramus, the 
fragment will be displaced inward by the action of the mylo-hyoideus, 
upward by the action of the masseteric, and forward by the action 
of the pterygoidei. If the fracture be single, and beneath the attach- 
ment of the masseter, crepitation will be present, but little displace- 
ment. If the neck of the bone is broken, the body is dragged for- 
ward by the action of the pterygoid, crepitation and mobility will 
be very apparent, and much pain will attend the movements of the 
jaw, produced by the displacing action of the temporalis. 

Pain, soreness, inability to masticate, inflammatory phenomena, 
impediment to speaking or swallowing, associate with and charac- 
terize the accident. In short, the history of a fractured jaw is the 
history of a fracture anywhere else, allowing for differences in office. 

Fractures of the superior maxilla are quite infrequent, and when 
they occur, except from extraordinary causes, demand little attention 
outside of that which pertains to the injury as a contusion. Of such 



FRACTURES OF THE MAXILLARY BONES. 625 

fractures I have treated a number which surprises me, considering 
the rarity of the accident ; but in no instance, outside of the alveolar 
fractures, have I met with a displacement which required apparatus 
for its cure. Indeed, the cellular character of these bones, and the 
existence of the antra, permit of such yielding that depression of the 
substance of the bone commonly forms the displacement : hence the 
associated frequency of caries with such accidents, the vitality of 
the part being lowered or destroyed. It is not, however, to be un- 
derstood that displacements do not occur ; the force of an injury may 
be great enough, as cases are on record to show, to displace the 
bones in mass. In Mr. Heath's work is the record of a case taken 
from the Chirurgical Treatise of Richard Wiseman, which is a 
marked example of such displacement. The patient was a lad eight 
years old, who had received a blow on the middle of the face so 
severe that he appeared at first to be dead, and afterward lay in 
prolonged coma. "When," says Mr. Wiseman, "I first saw the 
boy, he presented a strange aspect, having his face driven in, his 
lower jaw projecting forward. I knew not where to find any purchase, 
or how to make any extension. But after a time he became sensible, 
and was persuaded to open his mouth. I saw then that the bones 
of the palate w T ere driven so far back that it was impossible to pass 
my fingers behind them, as I had intended; and the extension could 
be made in no other way. I extemporized an instrument curved at 
its extremity, which I engaged behind the palate, and, having car- 
ried it a little upward, used it to draw the bone forward, which I did 
without any difficulty ; but I had hardly withdrawn the instrument 
when the fractured portions went back again. I then contented my- 
self with dressing the face with an astringent cerate. I likewise 
prescribed bleeding, and some hours afterward I had an instrument 
better constructed to reduce the large mass of displaced bone to its 
proper position. I had it held by the child's hand, by that of its 
mother or of an assistant, each for a certain time. Nothing else was 
done. Thus, by our united attention, the tonicity of the parts was 
maintained, the callus was developed, and in proportion as it became 
solidified the parts became stronger, the face assumed a good appear- 
ance, — certainly better than could have been hoped for after such 
marked displacement, — and the child was entirely cured." 

A cast in the Westminster Hospital, of a frightful deformity pro- 
duced by the passage of a wagon-wheel over the face of a man who 
fell in the street, is also alluded to. " Here the bones were com- 
pletely shattered, and the maxillae were torn from one another, and 

40 



626 ORAL DISEASES AND SURGERY. 

death was instantaneous." A case is also recorded admitted into the 
same hospital in 1860, resulting from the overturning of a cab upon 
the face of its occupant, who at the moment was leaning out of the 
window to direct the driver. Here, in addition to a fracture of the 
lower jaw, a little to the left of the median line, the nasal bones were 
broken, both malars were loose and separated from their attach- 
ments, and the left bone was fractured, as also the external angular 
process of the frontal bone. Though not positively ascertained, the 
vomer was no doubt fractured, and probably the vertical plate of 
the ethmoid too. The case is reported by Dr. Fyfes, in the Lancet, 
July 18, 1860. "It was remarkable," says this gentleman, "to 
observe how movable the bones of the face were. On watching the 
profile of the patient while he was in the act of swallowing food, the 
whole of the bones of the face were observed to move up and down 
upon the fixed part of the skull, as the different parts were brought 
into motion. It appeared as if the integuments only retained them 
in their position. It was a curious feature in the case, that notwith- 
standing the very extensive injury done, and the violent character 
of the force which caused them, not a single tooth was fractured 
or misplaced." This patient is reported as having made a perfect 
recovery. 

Of gunshot injuries I have had an opportunity to see some marked 
examples. In comminuted fractures it has been my practice to pick 
away such pieces as were completely detached, but to leave and 
mould, when feasible, all others in place. I never met with trouble 
from uncontrollable hemorrhage, and generally found the reparative 
energy sufficient to unite the comminuted parts. In Circular 
No. VI. of the Surgeon-General's Department, however, secondary 
hemorrhage is noted as the principal source of fatality in the reported 
cases : 1579 cases of fractures of the facial bones are reported; and 
of these 891 recovered, 171 died, — the terminations of 517 cases 
being left still unaccounted for. 

The following extract, copied from Mr. Heath's Essay, is from 
the Official Medical and Surgical History of the British Army in 
the Crimea: "Wounds of the face," says the report, "though pre- 
senting often a frightful amount of deformity, are not generally of so 
serious a nature as their first appearance might lead the uninitiated 
to expect. The reason for this, apart from the fact that the face 
contains no vital organ, seems obviously to be the very free supply 
of blood the part receives. From this cause, the fleshy structures 



FRACTURES OF THE MAXILLARY BONES. 627 

readily heal, and even the bones are so supplied that extensive 
necrosis rarely happens. The bony tissues, also, are softer than the 
long bones of the extremities ; and we therefore here but seldom 
meet with long fissures and extensive necrosis as a result of concus- 
sion of bone so often seen in them. This leads us to the very im- 
portant practical inference, not in this situation, as a rule, to remove 
bony fragments unless the comminution be great, or the fragments 
completely detached from the soft parts. Even partially detached 
teeth will often be found not to have lost their vitality, and, if care- 
fully readjusted, will become useful. There is, indeed, no great 
object, beyond perhaps the present comfort of the patient, to be 
attained in removing either fragments of bone or loosened teeth in 
the great majority of instances. If they die they become loose, and 
are readily lifted away, without trouble to the surgeon and but little 
pain to the patient. This observation is especially applicable to 
fractures of the lower jaw. Surgeons in this war have seen so many 
cases of badly-fractured instances of this kind unite, and that with 
a very small amount of deformity, that men of experience are now 
excessively chary of removing any portion of this bone unless it has 
become dead, or the fragment is so situated as to interfere consider- 
ably with the adjustment of the remainder, or the bone so much 
comminuted as to give no probable hope of its becoming consolid- 
ated, or so sharply angular as to threaten further injury to the soft 
parts or to interfere materially with their adjustment and retention 
in situ. In these fractures of the lower jaw, much less support and 
adjustment than we are in the habit of thinking advantageous in 
ordinary cases of fracture of it will frequently be found necessary, 
or even admissible. A complicated apparatus cannot be borne at 
first, on account of the condition of the soft parts, and a slight sup- 
port by a gutta-percha or Startin's wire splint, and a split bandage, 
is all that can be done. Any attempt at ligaturing the teeth is very r 
generally not only useless, but injurious ; and it is surprising how 
the parts often, as it were, adjust themselves, with but little aid 
from the surgeon." 

The treatment of a fractured jaw involves the indications to be 
met, and the mode or modes of meeting them. These indications 
and modes must of course vary with almost every individual case. 
For a simple fracture of the inferior maxillary, or, indeed, as well 
for compound fractures, the common pasteboard or gutta-percha 
splint will generally be found sufficient and reasonably satisfactory. 



628 



ORAL DISEASES AND SURGERY. 



To make this splint, take a piece of binder's board, or gutta-percha, 
and cut it as designated in Fig. 230. 

The board thus cut is soaked in hot water until it becomes suf- 
ficiently softened. The fracture is then set, and the splint moulded 
into shape and position. To do this, it is only necessary to lay the 
centre of the board beneath the chin, one-half projecting; the wings 
are now brought up and moulded to the cheeks ; next take the pro- 
jecting portion and mould it around the chin and sides of the face. 
This makes a complete cap, accurately fitting the parts, and, when 
dry, is uniform and unyielding. To hold it in position, a bandage 
must be applied. The most simple is a modification of Barton's, 
which suggested itself to the author some five or six years back, and 
which has since been used with much satisfaction. The Barton 

Fig. 230. — Barton's Bandage. 




A. Shape of the piece of gtf tta-percha for the chin. B. The same moulded to the part, 
—the ends, 1, 1, heing turned upward, and the sides, 2, 2, turned from before backward. 



bandage, so generally employed in fractures of the lower jaw, con- 
sists of a roller eight yards in length and from one and a half to two 
inches in width,— following in this latter respect the taste and idea 
of the operator. To apply this bandage, place the initial extremity 
behind the left ear ; carry it around the side of the head, over the 
right parietal bone ; cross to the right over the neighborhood of the 
fronto-parietal suture ; carry down beneath the chin ; carry up on the 
opposite side ; cross on the forehead ; carry around the left parietal 
bone, and meet the beginning of the roller at the occipital promi- 
nence, or a little below it j continue the turns until the bandage is 
exhausted. 




FRACTURES OF THE MAXILLARY BONES. 629 

Gibson's bandage, used in the same and similar fractures, mostly 
employed when the break occurs at the FlG 2 31.-Gibson's Band- 
angle, consists of three distinct turns. age. 

First. Place the initial extremity in front 
of the ear; carry down beneath the chin; 
pass up on opposite side, and meet the 
initial by passing over the fronto-parietal 
region far enough back to prevent slip- 
ping; repeat this turn three times. Second. 
Reverse in front of and a little above the 
ear, and make three turns around the cir- 
cumference of the vault. Third. End the 
third of these last turns at the occiput, 
and carry three times around the occipito-mental circumference. 
This is also an eight-yard roller. 

The modification of the Barton bandage, which I find to answer 
every purpose in my own practice, and which possesses the virtues 
of ease in application, removal, loosening and tightening, is applied 
as follows: Take a strip of roller material, one and one-half or two 
inches wide, one and one-half yards in length. Standing behind 
the patient, rest the chin on the centre of this strip ; carry the ends 
up, cross on the forehead, carry around the sides of the cranium, 
cross again at the occiput; carry now forward, and tie, or otherwise 
fix, in front of the chin. 

In the application of this dressing or strip, if the parts about the 
jaws are tender, it is better to make the termination somewhere on 
the side of the cranium. To effect this, it is only necessary to place 
the chin, when first resting the strip, nearer to one or the other of its 
ends. The character of this bandage is shown in Fig. 231. 

A second method of dressing a simple fracture, one which allows 
the mouth to be partially open, consists in making two plates, one 
to fit the upper teeth, in part, and the roof of the mouth, the other to 
cap a certain convenient number of the lower teeth. After setting 
the fracture, these plates are put in position, and attached to each 
other by means of a piece of wax ; the attached plates are now re- 
moved from the mouth and soldered together. This done, the piece 
is replaced, and the teeth are closed into the metal sockets ; the strip 
bandage is next applied, and the dressing is completed. This mode 
of treating a fracture of the lower jaw I thought original with my- 
self, but have found it employed by Mr. Liston, of England, some 
twenty years or more back, a splint entirely similar having been 



630 ORAL DISEASES AND SURGERY. 

constructed by Mr. Nasmyth at least five years before the idea sug- 
gested itself to my mind. 

Fig. 232.— The Author's Bandage. 




In any ordinary fracture of the lower jaw, the mode of dressing 
described will be found to meet all indications. In complicated in- 
juries, it has been the common experience that rules are of little or 
no consequence ; the surgeon will find himself governed and directed 
by the peculiarities of each case, and will be thrown entirely upon 
his own judgment and ingenuity. Perhaps no better exemplification 
of this fact exists than was exhibited in the practice of Dr. T. B. 
Gunning, of New York, in the case of Secretary Seward. The ideas 
of Dr. Gunning are multitudinous in this direction ; and while his 
professional sense has prompted him to the fullest exhibit of every 
means he has employed, yet I am well satisfied, from what I know 
of the profession at large, that the arrangements are too complex to 
come into general use. The monograph published by this gentle- 
man should, however, be in the hands of every surgeon. I know of 
few who seem to have studied the subject with more care or who 
have brought to it more enthusiasm and judgment. 

Fig. 233 represents the inner surface of a very simple splint used 
by Dr. Gunning, which incloses all the teeth and part of the gum of 
the lower jaw. This splint, as will be seen, would be very applicable 
where there were teeth on either side of the fracture, where there 
was little tendency to vertical displacement, and where there was an 
absence of swelling and undue tenderness. The holes marked A are 
for purposes of cleanliness, being large enough to receive the point 
of a syringe-nozzle. When in position, the jaws are to be closed, 



FBACTURES OF THE MAXILLABT BONES. 631 

the plate simply resting against the upper jaw or teeth ; the strip 
bandage, as described, may be thrown around the jaw and head. 
Dr. Gunning uses this splint without fastenings, but not unfrequently 
finds it necessary to secure it in place by ligatures, and in some 
instances by screws, which are made to pass into or between the 
teeth. In cases of much tendency to displacement, Dr. Gunning uses 
a splint very similar to the one which had previously suggested 
itself to Mr. Nasmyth and afterward to myself, — not so good or 
convenient, however, I am compelled to think, as it unnecessarily 
covers too many teeth, and is thus made cumbersome. This second 
splint is shown in Fig. 234. 

Fig. 233.— One of Dr. Gunning's Fig. 234.— Dr. Gunning's 

Splints. Second Splint. 




To secure this splint in place, screws are used. C represents an 
opening left between the conjoined splints, for food, speech, etc. ; D, 
a channel for the saliva from the parotid gland to enter the mouth. 
E is a screw used in the retention of the piece. 

The third modification of Dr. Gunning (Fig. 235) consists in the 
attachment to his splint of wings of steel. This is used in cases 
where the teeth have been lost in either jaw. F, upper wing; G, 
lower wing ; H, mental band, to hold the jaw up in the splint ; I, 
neck-strap, to keep the band back ; K, balance-strap, to hold the cap 
in place. 

Fig. 236 is a splint devised by Dr. Gunning to answer general 
cases. He suggests, first, the moulding of six or eight sizes, to be 
kept ready for use, from which one is to be selected suitable for any 
particular case presenting. The wings are of malleable iron, tinned 
to prevent rusting, and for more ready soldering. These sizes, he 
thinks, would be sufficient to select from. The splint should have a 
handle in front, that it may be used as a cup to take the impression 



632 



ORAL DISEASES AND SURGERY. 



of the jaw, the holes being useful to allow a small probe to be passed 
through the wax down to the teeth, thus allowing air to enter to 
facilitate the removal of the impression, and, when in use as a splint, 



Fig. 235.— Dr. Gunning's 
Third Splint. 



c — 




Tig. 236.— Dr. Gunning' 
Fourth Splint. 




giving entrance to warm water, thrown from a syringe, to keep the 
parts clean. 

The splint should be made to fit well by bending, cuttiDg off the 
edges, and rounding them off smooth. When a tooth projects so 
as to keep the splint from fitting, a hole may be cut to let it through, 
if the metal cannot be hammered out. This should all be done 
before taking the impression, as a well-fitted cup assists greatly in 
this important matter. 

A splint devised by Dr. Bean, of Georgia, used with decided 
success during the war of the rebellion, among the Confederate 
troops, is in its character similar in principle to that of Dr. Gunning. 
The interdental portion is almost precisely the same. A modifica- 
tion consists in the use of a mental compress. This is simply a 
" piece of light wood, four and a half inches in length, three-six- 
teenths of an inch in thickness, and one inch and a half in width 
in the middle, tapering to seven-eighths of an inch, and round at 
the ends, to each of which is attached a metallic side piece four or 
five inches in length and from three-quarters to one inch in width, 
also a shallow cup, fitting the apex of the chin. Incasing these 
side pieces are temporal straps, made of stout cloth, and secured 
by a strong cord at the base of each piece. 



FEACTUEES OF THE MAXILLAEY BONES. 633 

" A bandage, occipitofrontal, is composed of a band passing 
around the head from the forehead to the occipital protuberance, 
and secured by a buckle, one inch to the right of the median line 
behind, of another strap secured to the band in front and behind, 
and a third, extending from the temporal buckles on either side and 
secured to the middle strap at the point of crossing." 

It is sometimes the case that from comminution, or other causes, 
fractures of the inferior maxilla, like fractures of other bones, fail to 
unite. Necrosis intervening frequently prevents such union. In 
treating these cases the practitioner will find each to have its special 
indications. If necrosis exists, the exfoliation of the sequestrum 
must be awaited. In the few cases where the vital forces seem at 
fault, they are to be stimulated and elevated. If it occurs that the 
ends of the fragments have become rounded, and perhaps tipped 
with cartilage, operative means must of necessity be resorted to, — 
such means varying with the circumstances. One plan, much ap- 
proved, is to pass through the parts a seton, composed of several 
strands of wire, to be removed strand by strand, as inflammation is 
to be modified. Or, in place of the wire, other material may be 
used, as silk, thread, tape, etc. Another operation consists in boring 
one or more holes through each of the fragments, and tying them 
together with sutures of wire. Resecting the ends is still another 
means successfully employed by many. Irritating the ends, and 
thus provoking the desired inflammatory action, by rubbing the 
fragments together, is still another plan. 

Attention to the circumstances of a patient suffering from ununited 
fracture is important. A case exhibited several years back, at the 
clinic of the University of Pennsylvania, by Professor Henry II. 
Smith, was plainly enough due to the individual having confined 
himself exclusively to a diet of potatoes, such diet, in this case at 
least, being insufficient to accomplish the repair. The case of Mr. 
Seward comes, in many respects, within the category of the ununiting 
fractures, the means to overcome which constituted the skill em- 
ployed, the causes here being necrosis and non-fixedness. 

Complications, whatever their character, are to be treated on 
general principles. It is impossible to direct any special course, 
because of such conditions being constant to no rule. Hemor- 
rhages, so frequently alluded to, I have never met with of any par- 
ticular moment. When they do occur, however, they are nearly 
always secondary in character, and it may be well, where possible, 



634 ORAL DISEASES AND SURGERY. 

to treat them in anticipation : for example, an injury which has 
lacerated the facial artery would perhaps yield little or no hemor- 
rhage at the time of accident ; yet, as the process of sloughing 
should expose the sound part of the vessel, hemorrhage might be 
profuse and alarming enough. In these and corresponding cases 
circumstances might, in special instances, justify one in searching 
for the ends of the vessels and ligating them. Injuries to the teeth 
are to receive due attention : it is not by any means every loosened 
tooth that is to be removed, or every displaced one that is to be 
looked on as lost to usefulness. Fractures occurring about the neck 
of the inferior jaw are to have the displacements corrected by the 
application of such compresses as are found to answer the purpose, 
no matter how closely such applications follow any special rules, or 
how far they depart from them. I do not remember in the course 
of my professional life ever having treated two fractures precisely 
alike. 

In fractures of the superior jaw, complications are still more 
anomalous. Thus, I remember being compelled in one case to re- 
move the whole alveolar process of both superior maxillaB, the 
result of a kick received from a mule. In this case the patient was 
a man broken down by drink and dissipation. I anticipated by 
compulsion a process which I felt sure would have resulted, but 
which, to have been accomplished per vias naturales, would have 
cost the patient weeks of suffering, and, not unlikely, life. I have 
seen a case of fracture of the right upper maxilla, where the alveolar 
process (the fractured part) hung at least a quarter of an inch below 
the common level. In this case the part was moulded back into its 
place and supported by a simple strip passing across the jaw and 
fixed a little beyond the fronto-parietal suture. In three days the 
part became self-supporting, and in two weeks the patient was eating 
comparatively solid food. 

Gunshot injuries of the face and jaw are of every conceivable 
variety. The surgeon does primarily, in such cases, all that he can, 
and rests his hopes on nature. 

With Hamilton, we-have to remark that it is " impossible to dis- 
cuss in detail all the varieties of accidents to which the complicated 
structures of the face are exposed from balls or other missiles." 

Certain general rules are, however, to be observed. For instance, 
as suggested by this surgeon, '■' Missiles entering and lodging in the 
face ought to be extracted as speedily as possible ; and, whenever it 
is practicable, they should be removed through the mouth. If per- 



FRAGTUBES OF THE MAXILLARY BONES. 635 

rnitted to remain, they expose to the danger of secondary hemor- 
rhage, and increase the chance of subsequent disfigurement. 

" Loose fragments of bone should be speedily replaced, unless 
very much detached from the flesh and periosteum, experience having 
proven that they unite in most cases with facility. 

" Xo piece of skin which is torn up should ever be removed unless 
it is absolutely dead ; but it should be laid back carefully in place, 
and retained either by a few delicate sutures, or by some other gentle 
means of support. Tight ligatures and firm straps of adhesive 
plaster are apt to bind the tissues and destroy their little remaining 
vitality. The best means of supporting a fragment of skin in place, 
in many cases, is to lay upon it a thin piece of lint smeared with 
cerate, and over this a pledget of cotton-batting, securing the whole 
with adhesive plaster or a roller. 

"As soon as the inflammation and consequent induration have 
completely disappeared, and not before, it will be proper to make 
the final anaplastic operations." 

An addendum to these suggestions of Dr. Hamilton is to be made 
by directing attention to the necessity of controlling and combating 
inflammation. To this end cold water is to be freely used locally, 
saturated cloths being renewed as the temperature is elevated ; or 
the water may have to be medicated, acetate of lead and laudanum 
generally being added. A very admirable antiphlogistic applica- 
tion is prepared by adding to ^xvj of water 3D of the former and 
^ij of the latter. If a patient should be robust and plethoric, it 
will in most cases be advisable to assist the local treatment by 
cathartics, — sulphate of magnesia or the ordinary Seidlitz powder 
being employed. 

Imperfectly treated fractures not unfrequently induce so much 
discomfort as to warrant secondary fracture. As an illustration, 
the following case may be cited : T. H., an employe on the Camden 
and Amboy Railroad, received a double fracture of the inferior jaw, 
by being in some way jammed between two cars while in the dis- 
charge of his duties, — one break being on the line separating the 
second and third molar teeth, the other, the line of the cuspis root of 
same side. A treatment resorted to failed to retain the intermediate 
part in place, so that in uniting the teeth lay flatwise, presenting 
the buccal face as an articulating surface. 

Deciding upon the propriety of an attempted correction, the bone 
was rebroken through the unsolidified callus, and the depressed por- 
tion, being raised into position, was retained by a silver splint, — 



636 ORAL DISEASES AND SURGERY. 

this splint being made and applied exactly as described on page 621. 
As a consequence of the injury inflicted, several pieces of the callus 
necrosed and came away; but the daily injection of the parts with a 
much-diluted compound tincture of capsicum resulted, in the course 
of six weeks, in such solidification of the parts in their new position 
as to permit the disuse of the splints, — terminating in a cure most 
satisfactory to all concerned. 






CHAPTER XXXI. 

DISLOCATION OP THE INFERIOR MAXILLA. 

The frequency of this accident, the terror which it excites, and 
the harm resulting when not properly cared for, give to it an impor- 
tance which renders a careful appreciation of it a matter of much 
concern. 

There are four forms of submaxillary displacement: complete dis- 
location, incomplete, bilateral, and unilateral. In the first of these, 
one or both condyloid processes have slipped fully out of the glen- 
oid fossae and rest entirely in front of the articulating eminence, 
as exhibited in the view. 

Fig. 237. — Complete Dislocation of Jaw. 




In the second, the condyle rests upon the interarticular fibro- 
cartilage, directly over the articulating eminence, and will remain 
fixed, or may fall backward or forward as directed by accident, 
not being retained in its position, as is frequently thought, by the 
coronoid process being hooked under the malar bones, but resting, 
as it were, upon a point, with complete balance in the muscular 
structures. 

A bilateral luxation is a displacement of both condyles, and is of 
somewhat more frequent occurrence than the unilateral, or displace- 
ment of one side« 

( 637 ) 



638 ORAL DISEASES AND SURGERY. 

The diagnosis of a luxation is an exceedingly simple matter. An 
open mouth, with inability to close it, the lower jaw thrust forward in 
a straight line, or otherwise turned to the right or left, according to 
the accident, indicates a luxation of bilateral or unilateral character. 

The exciting causes of dislocation are various : yawning, vomiting, 
putting large bodies into the mouth, blows received upon the chin 
from above downward, or in front, while the mouth is open ; the 
extracting of teeth, or extending the jaws widely for the convenient 
filling of them. The first case I ever met with occurred in a middle- 
aged man while laughing immoderately. 

The predisposing cause of the accident resides in a general or 
special laxity of the articular connections: thus, all are acquainted 
with persons who without effort will dislocate a finger or a toe. I 
have met with instances where the operation of removing a tooth 
was always attended with unilateral luxation unless a mento-occi- 
pital sling was used. 

What is the condition of the parts in luxation ? By placing the 
finger immediately in front of the tragus of the ear when the mouth 
is closed, and carrying it forward along the zygoma, the surface is 
found to be a plane. If the finger is kept on the surface, and the 
mouth opened, it is felt to drop into a fossa. This fossa is the glen- 
oid ; the concave rim above is. the border of the cavity ; the rounded 
prominence below is the condyle of the lower jaw. Placing the jaw 
of the cadaver in this position, and dissecting down to the articulation, 
the condyle is found slipped forward, resting upon the interarticular 
fibro-cartilage ; the fossa has been partially vacated, and the bone 
rests against the articulating eminence. If now the condyle is dragged 
downward and forward over the eminence, the glenoid cavity will be 
found completely vacated, and, unless by manipulation, the condyle 
cannot be restored ; laying back now the soft parts, the cavity in 
front of the tragus will be found greatly increased, the finger falling 
into the unoccupied fossa. (An added diagnostic sign is then found 
to be increased depth and size of the fossa in front of the ear: this it 
is desirable to remember, as a fracture of the neck might simulate a 
luxation.) Returning to the examination, we find that to reduce 
the dislocation it is necessary to depress the head of the bone below 
the level of the articulating eminence, which, now being back of the 
condyle, serves to fix it in its abnormal position, as originally it 
was the means of its retention in place. But we pass to the con- 
sideration of the associate parts : the capsular ligament we do not 
find torn, as a rule, but stretched and elongated ; the lateral liga- 






DISLOCATION OF THE INFERIOR MAXILLA. 639 

ments do not seem particularly interfered with, and impress us as 
having little influence in the matter, one way or another; the tem- 
poral muscle shows itself stretched and dragged forward, but is 
seldom torn ; the pterygoid and masseter are relaxed. 

Dislocation is of more frequent occurrence in women than in men, 
is uncommon in children, and rare in the robust. When a disloca- 
tion has existed for a long time, there seems a tendency on the part 
of nature to make some compromise with the condition ; the jaw 
will gradually recover considerable of the lost motion, and I have 
seen cases where the patient seemed to be able to masticate his 
food without the least trouble. The original contour of the face I 
have never, however, seen entirely restored. 

A luxation of the lower jaw, like the luxation of any other bone, if 
left unreduced, even for a very few days, will be found difficult to 
replace ; the muscles become contracted, the condyle settles itself in 
its new position, lymph is effused and coagulates, and the general 
aspect and relations of the joint are changed. A patient, however, 
so situated, is not to be left unassisted, or to the relief afforded by 
nature. A satisfactory practice in cases of this kind, where a 
luxation may not be immediately reduced, is found in wedging corks 
between the teeth, forcing the back part of the jaws as far asunder 
as possible, and then with a properly directed compress and band- 
age approximating the anterior teeth, and at the same time forcing the 
lower jaw backward. This manipulation, assisted by the employ- 
ment of sorbefacients, not unfrequently results in the absorption of 
the semi-organized lymph and a consequent ability in the bone to 
reoccupy its original cavity. 

Reduction of a luxated jaw has been accomplished as long as 
ninety-eight days after the occurrence of the accident. 

Subluxations are of very common occurrence, particularly among 
weak women of easy means and luxurious lives. In England, at- 
tention was first directed to the condition by Sir Astley Cooper ; in 
this country it certainly has needed no particular one to discover it, — 
a proof, perhaps, of the physical superiority of English over Amer- 
ican ladies. This condition depends, evidently enough, upon a laxity 
of the ligaments, and perhaps more particularly on the weakness of 
the muscles of the part. In yawning, or not unfrequently in ordi- 
nary mastication, the condyle will slip forward on the articulating 
eminence, and, for a moment, the mouth cannot be closed, requiring, 
in many cases, the assistance of the hand to effect it. Depending on 
weakness, a permanent cure is only to be looked for as a higher and 



640 • ORAL DISEASES AND SURGERY. 

stauncher vitality is secured. Thus, such a tendency and condition 
are to be treated by cold bathing, tonic medication, exercise, etc. 
In the case of a lady liable to such luxation, and who was made 
very nervous by its occurrence, the accident was entirely guarded 
against by the patient wearing the occipito-mental caps and bands. 
I was once consulted by a lady who was awakened almost every 
night by the peculiar and unbearable pain attendant on such slipping 
of the condyle during the relaxation of sleep. 

Dislocations associated with fracture are, happily, of very rare oc- 
currence. I myself have never seen a case, unless, indeed, it existed 
in association with certain gunshot wounds, when an appreciation of 
the condition, if existing, would have been of very little moment. 
Delamotte records a case where, in the person of a girl, double lux- 
ation existed with fracture of the body of the bone. Another is 
recorded by Roberts, where the body was broken in front of the right 
ramus, and the condyle dislocated outward. A third case (Heath) 
is reported in the Dublin Medical Gazette, and " occurred in a boy 
of eight, who suffered a fracture at the symphysis, with dislocation 
of the left condyle upward and backward. There was bleeding from 
the ear, and the chin was much retracted and turned to the left ; the 
mouth was open, but could be closed, and it was then observed that 
the lower molars overlapped the upper, but that the lower incisors 
were at least one inch behind the upper. Reduction was easily 
effected, and the case did well." 

Luxations are sometimes congenital. The first case of this kind 
was noticed by Mr. Robert Smith, of Dublin, who gives with mi- 
nuteness the results of his dissection. The patient, an idiot from 
infancy, died at the age of thirty-eight. The luxation existed on the 
right side, which was remarkably deformed, having a singularly hol- 
low appearance, which strikingly contrasted with that of the sound 
one, which was unusually full and plump. The extremity of the 
finger could be readily pressed between the posterior margin of the 
jaw and the auditory canal, owing, as was found on dissection, to 
the absence of the condyle of the bone, which was, in fact, greatly 
atrophied nearly as far forward as the symphysis. There was no 
interarticular cartilage or distinct capsular ligament, and the mas- 
seter, pterygoid, and temporal muscles were much wasted. The 
temporal, malar, superior maxillary, and sphenoid bones were im- 
perfectly developed, and the glenoid cavity existed merely in a rudi- 
mentary state. 

Treatment of Luxation. — By referring back to Fig. 237, it will be 



DISLOCATION OF THE INFERIOR MAXILLA. 641 

plainly evident that the reduction of a disarticulated condyle con- 
sists in getting it back of the eminentia articularis. How best to do 
this is the question. 

1st. Wrap the thumb in delicate napkins, seat the patient on a 
strong chair, and, standing behind him, rest his head against your 
person ; place now the protected thumbs upon his inferior molar 
teeth, and with main strength force the jaw directly downward and 
a little backward: the moment you have depressed the articulating 
face of the condyle, it will be felt to be dragged into place. The 
amount of force required to depress the condyle depends entirely 
upon the muscular tone of the individual. In some cases the reduc- 
tion is effected almost before you are aware of having exerted any 
pressure; in others it cannot be secured without the assistance of 
mechanical appliances. 

Fig. 238. 




2d. Failing to reduce a luxation standing behind a patient, reverse 
the position, resting the head against an assistant. 

3d. Take corks, one or two, according as the luxation is single or 
double, force them between the wisdom-teeth of the upper and the 
lower jaw as firmly and fixedly as possible ; now gradually force the 
chin forward and upward, using either the hands, or a tourniquet 
applied around the head. 

4th. Take a piece of wood about a foot in length, place one end 
upon the molar teeth of the luxated side, make a fulcrum of the 
molar teeth of the upper jaw of the opposite side, and elevate the 
end held in the hand. If the luxation is double, reduce one side at 
a time. In the use of this lever, I have secured the result more easily 

41 



642 



ORAL DISEASES AND SURGERY. 



by resting the centre of the piece of wood upon the molar teeth of 
the side to be reduced, carrying the end downward. I think it will 
be found the most satisfactory application of the power. 

The forceps invented by Stromeyer yields a powerful leverage. 
This consists of two blades so expanded at the extremities as to fit, 
as well as may be, the dental arches, these blades being covered 
with leather ; a spring between the handles throws them apart, 
thus closing the blades. Reduction is attempted in two ways. Intro- 
ducing the padded blades so that each shall rest upon its proper tooth 
or teeth, — the third and second molars, — the handles are grasped 
in the hands of the operator and gradually brought together; when 
the blades have thus been so far separated that it is inferred that the 
face of the condyle is below the level of the obstructing eminence, 
the jaw is to be pushed forcibly backward into its place by an 
assistant. 

Another method of using this instrument is the employment of 
a screw and nut which passes between the blades : a delicate 

wrench fits this nut, and through 
Fig. 239 - its instrumentality the handles are 

gradually screwed together, sepa- 
rating of course the blades. The 
manipulation of pushing back the 
jaw, Stromeyer suggests, should be 
effected at the same moment as the 
sudden closing of the blades. Even 
better, however, than the Stro- 
meyer forceps is the instrument 
figured on page 207. With this it 
is easy to secure the required de- 
pression, when the condyle, not 
unlikely, is found to slip into place 
of its own accord. 

5th. Still another method is that 
known as Nelaton's. To practice 
this, the patient is seated upon a 
common chair, and the surgeon, 
standing behind, fixes his thumbs 
upon the nape of the neck, while 
with his fingers he pushes the jaw forward and downward by 
pressure exerted upon the coronoid prominences. 

6th. Anaesthesia. — In recent cases the anaesthetic agents may not 




Vertico-Mental Sling or Cap. 



DISLOCATION OF THE INFEBIOR MAXILLA. 643 

be required, although there is seldom objection to their employment. 
In cases, however, of any standing, or in muscular persons, it often 
happens that it is impossible to succeed in the reduction without 
the aid of relaxing agents ; while, again, the formation of adhe- 
sions will be found to make attempts at reduction both painful and 
formidable. 

A luxation having been reduced, it becomes necessary to give 
support to the parts, and insure for a time against the possibility of 
the mouth being too widely opened. This is most conveniently in- 
sured through the use of a vertico-mental sliug made with elastic 
straps. 



CHAPTER XXXII. 



OZ^ENA. 



The term ozaena, like the term epulis, is a somewhat indefinite 
one, and is to be first considered in the width of its signification. 

Ozsena is from the Greek d£>?, signifying " stench," and the term 
is, therefore, in reality, applicable to any ill-smelling condition. By 
universal consent, however, it has been restricted in its application 
to foul conditions about the nares and associate parts, accompanied 
with offensive discharge. The study of ozaena, then, it will be seen, 
is the study of various conditions, and may be considered under the 
following heads : 

1. Accumulation and degeneration of the common antral secretion. 

2. Degenerated pus from tooth-abscess discharging into the 
antrum. 

3. Ulceration of mucous membrane of the antrum. 

4. Deteriorated secretions from constitutional causes. 

5. Caries of the osseous walls of the antrum. 

6. Ulceration of the mucous membrane of the nares. 

7. Caries and necrosis of the osseous boundaries of the nares. 

8. Lodgment and retention of foreign bodies. 

1. The first of these conditions is most frequently observed in con- 
nection with the ordinary cold in the head. The outlet of the antrum, 
it will be remembered, is by an opening about the size of a goose-quill 
into the middle meatus, which opening is circumscribed by mucous 
membrane, and which membrane, as the result of congestion, can 
very readily occlude this outlet ; the parts being in this condition, it 
may happen that the pent-up mucus degenerates and decomposes, 
so that, on the subsidence of the swelling, the escaping discharges 
present this offensive odor. To diagnose this character of ozasna, it 
is only necessary to connect it with the preceding inflammation, with 
the absence of specific conditions, and with the readiness with which 
it yields to simple treatment. Of course there would have been a 
preliminary feeling of the sense of congestion on the part of the 
patient ; he would have had, to express it most simply, a cold in the 
(644) 



OZMNA. 645 

head, and this cold, with its sense of dryness and constriction, would 
have grown worse, until, with the appearance of the discharge, he 
would have experienced a sense of relief, — the discharge implying the 
passing away of the congestion and the restoration of the normal 
circulation and secretion. 

To cure this form of ozaena requires very little treatment, — indeed, 
in most cases no treatment at all. I am in the habit, when the 
discharge continues longer than two or three days, of directing the 
sniffing up the nostril of the affected side some such combination as 
the following: 

B. — JEtheris sulphatis, gj ; 

Tincturae iodinii, ^ij ; 

Olei juniperi, 3j- M. 

If this fails to check the discharge, I then employ such constitu- 
tional treatment as seems indicated. Patients in whom such dis- 
charge exists belong to one of two classes, the plethoric or the 
anaemic. With the first, the treatment demanded is depletory: a 
dose or two of sulphate of magnesia will generally be all that is 
demanded; although in a few instances I have found it necessary 
to deplete from the veins. With the second class — and this is by 
far the more numerous — we have the mucous membrane of the part 
falling into a condition analogous to the urethritis of chronic gonor- 
rhoea ; in these cases tonics are at once to be resorted to, and the 
common combination of iron and quinia is perhaps the best that can 
be prescribed : 

R. — Tincturae ferri chloridi, Jj j 
Quiniae sulphatis, 3j. M. 
Sig. — Fifteen drops in water every three hours. 

2. Fetid discharges depending on tooth-abscesses — abscesses 
which discharge into the antrum — find their cure, as a rule, imme- 
diately on the extraction of the diseased tooth. If this should not, 
however, prove to be the case, then injections are to be made 
through the tooth alveolus. Iodine is an admirable base for all 
such injections. My own practice would be first to control the 
odor with the permanganate of potash. 

R. — Potassae permanganatis, 3ss — j ; 

Aquae, 3viij. M. 
Inject as occasion requires. 



646 ORAL DISEASES AXD SURGERY. 

It would most likely be quite sufficient to use this injection three 
times a day. After it the following should be thrown in : 

R. — Tincturae iodinii, Jj ; 
Glycerinas, §j ; 
Acidi tannici, 3ss ; 
Aquae Colonise, Jj ; 
Aquas destillatae, §iij. M. 



Or, 
Or, 
Or, 



R. — Tincturae capsici compositae, jfss; 
Aquae rosae, ^viij. M. 

R. — Argenti nitratis, gr. xxx; 
Aquae, §vj. M. 

R. — Tini opii, 5j ; 

Vini aromatici, §j ; 
Aquae, gvj. M. 

Indeed, any stimulant preparation maybe resorted to; although I 
incline to believe that iodine acts the most happily. 

3. Ozaena from ulceration of the mucous membrane of the antrum 
is not, so far as my experience allows me to judge, a condition of fre- 
quent occurrence ; without doubt this is the case where no specific 
disease, as syphilis, scrofula, or scurvy, exists, so that, meeting 
with such ozaena, we naturally at once revert to the constitutional 
condition. To discover an ulcer within the antrum is a matter for 
diagnosis by exclusion, and thus to discover it is not at all a difficult 
matter. If there are no diseased teeth or teeth-roots, no nasal 
ulceration, no antral dropsy, no acute preliminary conditions ; if the 
fetid matter flows most freely when the suspected antrum overlies 
its nasal outlet, then w T e will generally be right in inferring an ulcer 
of the antrum ; but an ulcer in the antrum is not necessarily a 
cause of ozaena. To give this fetid odor, it must be an unhealthy 
ulcer, by which is meant that it tends to degenerate its granulations, 
rather than to organize them. An ulcer, says Mr. Cooper, may be 
defined to be "a granulating surface, secreting matter;" and this. is 
certainly true of most ulcers, particularly if we replace the term se- 
creting with the term making; for the matter given off is, I imagine, 
nothing but degenerated lymph-corpuscles, to which the parts lacked 
strength to give force of organization. A healthy ulcer may be 
seen in any accidental sore tending to rapid self-cure : there is here 



OZMNA. 647 

little or perhaps no matter, for the reason that every particle of the 
exuded lymph of repair has in it vitality sufficient for its organiza- 
tion. An unhealthy ulcer, on the contrary, — and by such an ulcer 
we mean an adynamic one, — gives off more or less pus ; it throws 
out its reparative lymph just as does the healthy one, but the via- 
bility of such lymph differs materially from the exudation of the 
former ulcer. Thus, according to the nature and character of such 
degeneration, we have the produced pus : ichorous, a thin, watery, 
acrid discharge ; scrofulous, a cheesy, curdlike pus ; sanious, a thin, 
sizy discharge ; glutinous and viscid, as in sordes, etc. 

Now, whether any or all of these kinds of ulcers should give us the 
fetor of ozaena, would depend on circumstances ; not the least im- 
portant of which would be the state of the atmosphere, and the 
cleanliness preserved. Laudable pus, issuing from a healthy wound, 
will, in hot weather, become quite offensive in a very short time, as 
is, unfortunately, too freely illustrated in hospital practice. Certain 
ulcers are, however, in themselves offensive. Every one has had 
occasion to observe, at some time or other, the disgusting odor 
arising from the saliva of particular persons, — constitutional ozaena 
it may with most propriety be termed. I recall, even to this day, a 
certain schoolmaster, the odor of whose spittle, employed to rub 
sums from my slate, always made me sick. This kind of saliva, 
and this odorous ulcer, belong to the alkaline class of people. Give 
such persons acid : they always need it ; I never knew an exception. 

A simple ulcer of the sinus — that is, one not associated with 
osseous diseases — is to be treated in the twofold direction of its con- 
stitutional and its local requirements. To treat an ulcer justly, calls 
for an understanding of the conditions on which ulcers depend; and 
as ulcers of various signification so frequently present themselves 
about the mouth and throat, it may not be a digression to make a 
hasty review of so enlarged and important a subject. 

Ulceration is the absorption or the breaking down of some con- 
stituent part of the body. Its great cause is inflammation. Inflam- 
mation is always preceded and excited by irritation. The term irri- 
tation is a comprehensive one, and covers every source of offense to 
the human body. Thus, one man has an ulcer, the result of an in- 
flammation excited and perhaps kept up by the presence of some 
foreign body, as, for example, a ball, a splinter of wood, a particle 
of dust, etc. An ulcer, says Richerand, is from a cause inherent in 
the economy, and differs from a wound, which is always idiopathic, 
in being symptomatic. A second man has an ulcer, the result of 



648 ORAL DISEASES AND SURGERY. 

a localized inflammation, predisposed by the presence within his 
system of some specific taint. These ulcers, a glance would exhibit, 
must vary widely in their character, and even more so in the treat- 
ment demanded for their cure. Thus it is that we speak of, and 
think about, ulcers in the way of their signification. We have simple 
purulent ulcers, venereal ulcers, scrofulous ulcers, scorbutic, varicose, 
and cancerous ulcers; the character of each being expressed by its 
adjectival prefix. A simple purulent ulcer is a sore, the result of 
some local accident, and is, most likely, self-curing; a venereal ulcer 
is one excited and kept alive by the presence in the system of the 
venereal poison; the scrofulous, scorbutic, and cancerous alike de- 
pend on dyscrasic conditions; the varicose on certain obstructions 
in the venous system, etc. To secure a cure in the first of these 
classes of ulcers, nothing more is necessary than to protect them 
from adverse influences. A varicose ulcer, to be cured, must be 
converted into a simple one by treatment directed to the trouble 
in the circulation; a cancerous, scorbutic, or scrofulous ulcer is only 
to be permanently cured by obliterating the cachexia. , There is 
nothing obscure in the appreciation of these facts ; the difficulty is 
in meeting the indications. Ulcers, it is true, are presented under 
a great variety of names; but these variations have reference only 
to varieties in expression. Thus, the carious ulcer implies that the 
condition is dependent on the presence of dead or dying bone ; a 
callous ulcer is one having an indurated circumference ; a fungous 
ulcer is one where the granulations of repair are in excess ; a sinuous 
ulcer is one constituting the orifice of a canal leading to a deeper 
than the manifested disease ; an irritable ulcer is one that, from in- 
ternal or external causes, has become tender and excited ; a phage- 
denic ulcer is one that tends to take on gangrenous action ; a sordid 
ulcer is one discharging a dirty-looking glutinous matter ; and so 
on, each of the many appellations being simply an expression of 
some distinctive peculiarity. Now, one man, having syphilis, gets 
a rheumatism in his joints; another gets an ulcer on his tibia. In 
these two cases the important features of treatment are, how- 
ever, to be precisely alike : both patients must have an antisyphilitic 
medication ; the local applications are simply adjuncts. An ulcer 
simple in its character, situated over or upon some part in frequent 
motion, is apt to assume the irritable aspect ; an ulcer the result of 
an idiopathic influence, if occurring on a person of weak and typhoid 
condition, is almost certain to assume the chronic or indolent form ; 
an ulcer engrafted by external cause on a depraved constitution is 



OZJENA. 649 

always more or less influenced by the vice, and such vice must be 
considered in its treatment; and so, whatever may be the extent of 
the review, this wide collateral relationship keeps itself in the fore- 
ground. 

To return, then, to ulcers in the antrum. "We are prepared to 
recognize that such ulcers may be of various signification, and may, 
for their cure, demand a various character of treatment. So far as 
the odor, however, is concerned, all will benefit by the common pri- 
mary treatment of cleanliness and antiseptic injections. To correct 
the fetor in a chronic case, it generally becomes a necessity either to 
trephine through the canine fossa, or to extract one of the underlying 
teeth and get into the cavity through its alveolus : the latter mode 
is decidedly to be preferred. A plan, however, that may be tried, 
consists in keeping a tuft of cotton or fine sponge in the nostril, and 
frequently saturating it by the sniffing into it of an antiseptic. The 
entrance into this cavity, however, through the alveolus of a tooth 
is one of the simplest procedures in surgery, demanding only that 
the operator shall recognize the position of the cavity as influenced 
by the shape of the jaw. Any spear-shaped instrument will answer 
to make the opening : to keep it patulous, it is only necessary to 
introduce, after each operation or injection, a tent of cotton or sponge. 
As an injection, the following combination may be employed : 

R. — Acidi carbolici, gtt. xx; 

Glycerinae, ^ss; 

Acidi tannici, gr. v ; 

Aquas, gvj. M. 
Or, 

B. — Spiritus vini, 3j ; 

Creasoti, gtt. x; 

Aquas, gvj. M. 

Or, as suggested on page 645, the permanganate of potash in the 
proportion of from two to ten grains to the ounce of water, as indi- 
cated. 

Phenate of soda, combining as it does antiseptic and alterative 
virtues, is one of the very best injections that may be employed in 
these cases. 

Associated with such antiseptic treatment, and which we use in 
every case of ozaana, whatever may be its origin, we connect the 
specific or peculiar treatment demanded by each special case, — the 



650 ORAL DISEASES AND SURGERY. 

understanding of which treatment presupposes and necessitates the 
understanding of disease in general, and can conform to no special 
rules. 

It is true that for certain diseases we have certain medicaments 
which we have come, perhaps unadvisedly, to consider too much in 
the light of specifics. Thus, in syphilis, the mercurials are much 
depended on ; so that, having an ulcer of such origin to treat, a con- 
stitutional medicine might be prescribed, as follows : 

B. — Syrupi ferri pyrophosphatis, ^vj ; 

Hydrargyri chloridi corrosivi, gr. iv. M. 
Sig. — A teaspoonful three times a dav. 
Or, 

B. — Hydrargyri iodidi, gr. ij ; 
Potassii iodidi, 3ij ; 

Syrupi sarsaparillse composite, ^viij. M. 
Sig. — A tablespoonful three times a day. 

Mercury is to be considered as an active force, striking at the 
parasite of syphilis, destroying it ; and while it is very well thus to 
kill such a parasite, it is quite as well to remember that the harm of 
the agent employed must be constantly met and counterbalanced. 
This we do by keeping up and supporting the system, so that I 
think it will commonly be found that syphilitic ulcers require, quite 
as much as a specific medication, wholesome food, fresh air, proper 
exercise, judicious bathing, — in short, the employment of every 
means that tends to the maintenance of the general health. 

In the mercurial ulcer of the antrum — which is far more common 
than the syphilitic, granting the true syphilitic to exist — the general 
and local use of the chlorate of potash is found to act very well. 
The medicine, dissolved in water, may be given in doses of ten 
grains, repeated four or five times a day; the injection should not 
be less in strength than a saturated solution. The character of a 
mercurial ulcer is discovered by associating the local lesion with 
the existing dyscrasia. 

Scrofulous ulcers are judged by the appearance of the sore, the 
nature of the discharge, and the existence of depression in the 
patient at large. A scrofulous subject, while not always bearing 
the clearest general evidences of the disease, usually has some one 
or more features that will allow us to distinguish the condition. 
General features associated with scrofula may be enumerated as 



OZMNA. 651 

follows : the first manifestation occurs generally, not always, at the 
period of first dentition, the symptoms being irregular appetite, an 
ill-smelling, inspissated mucus, and swelling of the superficial glands 
of the neck. Continued manifestations advance with age, presenting 
subcutaneous lymph effusion, particularly about the calves of the legs 
and the outside of the thighs ; various eruptions, inflammation, and 
suppuration of joints, especially the hip, knee, and thumb-joints ; a 
flaccid, enlarged condition of the tonsil glands, susceptibility to 
atmospheric changes, inability to endure physical fatigue, impover- 
ishment of the blood, general asthenia. Scrofulous subjects are 
generally languid in their movements, and without impressibility ; 
not always, however, for it is a well-known fact that many of the 
most precocious and bright persons end their effulgence in phthisis. 
In short, the history of scrofula may be viewed as the history of 
phthisis : it matters little, so far as a general effect upon an individual 
is concerned, whether tubercle deposits itself in the lung or in the 
ganglia, or whether there is deficiency in the developing force. 

Scrofulous ulcers are always unhealthy in appearance, being 
covered with a dirty-yellowish aplastic matter, irregular about their 
edges, generally bluish or purple, more or less undermined, and dis- 
charging an ichorous, flaky pus. Local stimulation meets with little 
or no response, and, for the reason of the general deficiency in 
vitality, the parts around are usually indurated from interstitial 
deposits, chronically congested, and looking altogether indolent and 
ill conditioned. 

The treatment of scrofulous as well as of the true tuberculous 
ulceration is (in our present knowledge of the disease) simply a 
treatment of building up. Unacquainted with any special materia 
peccans, we direct our aim so to lift up the life-forces that a suffi- 
cient inherent vitality may be developed to throw off or overmaster 
the depressing influence. Exercise, tonic medicaments, cold bathing, 
salt and mountain air, rare or raw meats, generous liquors, — all are 
useful means to such an end. Iodide of potassium has long had a 
reputation in this condition ; also barium, iodide of iron, syrup 
of the phosphates, cod-liver oil, phosphoric acid, etc. My own 
individual experience is, that wrapping one's self in a wet sheet 
on getting out of bed, and securing vigorous reaction by a good 
hand-rubbing, and, after such operation, drinking the yelk of a fresh 
egg drowned in good brandy or whisky, is better than any medicine 
proper yet prescribed. Certain I am that I have seen this treat- 



652 ORAL DISEASES AND SURGERY. 

merit do such good as warrants the commendation these remarks 
would give it.* 

We always, however, do something for a local disease, from 
mere force of habit, if for no other reason. We can use with these 
ulcers any of the applications referred to a few pages back, and any 
one of them is about as good as any other, or we may use them one 
after another. 

Syphilitic ozaena from ulceration of the antral mucous membrane 
must be, as we have remarked, an exceedingly infrequent affection. 
Not so, however, with ulceration from such cause in the naris ; such 
a condition is quite common. When you have a case in which dirty 
clotty scabs are constantly being received into the handkerchief, and 
much offensive sanies is discharged from the nose, you may feel well 
satisfied that you have a case of syphilitic ulceration, and particu- 
larly may you rest satisfied in your diagnosis if any evidences of the 
disease exist in other parts of the body. Syphilitic ulceration of the 
nose has frequently been confounded with a commencing polypus ; 
but the conditions are so dissimilar that only the most culpable care- 
lessness could fail to distinguish them. In the first condition there 
are the fetid discharge, and the association with the anterior train 
of accidents ; a scab soon comes away, and a temporary cessation 
of the obstruction ensues. In the latter disease the obstruction is 
apt to be gradual and continuous ; there are no fetid clots, and no 
anterior accidents of association : blowing the nose, in the one case, 
most likely relieves for the moment ; in the second, it throws for- 
ward the polypus so that we can see and feel it. 

Syphilitic ulcers within the nose attack equally any location, and 
possess the most unfortunate tendency to enlarge and burrow, so 
that, if not successfully combated, in a very short time the bony 
framework is involved, thus producing the deformities so common. 

A patient with a syphilitic ulcer developing in his nose com- 
plains first of a feeling of congestion. We come to our conclusions 
because we observe certain secondary indications. A few days, more 
or less, pass, and he is troubled with a discharge ; this, at first, is 
very slightly or perhaps not at all offensive. Very soon, however, he 
remarks the odor, and the discharge, which continues to increase, 
frequently becomes so profuse that twenty or thirty pocket-handker- 

* The author, for convenience, here combines the conditions of scrofulosis 
and tuberculosis, as at present we have but a common treatment for them, 
and thus nothing practical would be gained in separating them. 



OZMNA. 653 

chiefs are necessary for his daily use. Occasionally, and sometimes 
very frequently, dirty, gluey clots or scabs come away, and the 
ulcer, if seen, is noticed to present a reasonably healthy look, — 
something, for example, as a chancre would look when only half 
destroyed and casting off its slough. If uncombated and uncon- 
quered, the ulcer eats deeper and deeper, until the bone is reached, 
which, in. its turn, succumbs, giving us caries, or, much more likely, 
necrosis. Arrived at this stage, we have indeed a most formidable 
condition, and it is not at all unlikely that, in defiance of every effort, 
more or less deformity will result. 

An ulcer situated in the anterior part of the naris is indicated by 
the forced expirations of the patient. Situated well back, he relieves 
himself by forced inspirations; occasionally, however, from the very 
beginning the pituitary membrane becomes so thickened and en- 
gorged that the passage of air through the tube is almost shut off: 
in these cases the trouble is indicated by excessive restlessness. 

It is not by any means always the case that nasal ostitis is sec- 
ondary to ulceration : on the contrary, the cases are frequent enough 
where the bone becomes primarily diseased and where the ulcer is 
simply the associated lesion. Syphilitic ostitis very frequently ends 
in necrosis, and more particularly is this the case where the turbi- 
nated bones are the ones affected. The vomer, however, is the bone 
most frequently necrosed in syphilis, — that is to say, the most fre- 
quently attacked ; and this is brought about in three ways : first, 
from a primary ulceration of its mucous covering; secondly, by the 
deposition of submucous tubercles; thirdly, by the direct affection of 
the bone. When ostitis attacks the vomer or any other bone, our 
best efforts are to be directed to the resolution of the inflammation. 
To secure this end we resort to such local means as seem indicated 
by the peculiar features of the case. The treatment would be that 
applicable to inflammation anywhere; it could be influenced by the 
temperament of the patient and the stage of the disease. Locally 
we have at this time nothing to do with its specific character: we 
have simply to treat a perverted condition of the circulation of the 
part. Constitutionally, however, its origin is to attract our closest 
scrutiny; and, in connection with the local remedies employed, anti- 
venereals must be depended upon as our strongest supports. 

The diagnosis of inflammation of the nasal boundaries is not diffi- 
cult to make out. When the vomer is the bone attacked, the patient 
suffers from sharp pains, referred to the root of the nose ; he has 
headache, always increased by the recumbent position. If the in- 



654 ORAL DISEASES AND SURGERY. 

flamrnation exists in the anterior part, pressure on the cartilage 
increases the pain. 

The nasal bones, when affected, exhibit an overlying congested 
skin ; pressure on the bridge is responded to by much pain ; the 
lachrymal secretions are affected, and not uufrequeritly, because of 
the congestion in the ductus ad nasum, run over the cheek. The 
turbinated bones, when they are the seat of the inflammation, yield 
a soreness to the lateral aspects of the canal, and respond quickly to 
pressure exerted thereon. 

Whichever of these bones may be affected, its history, so far as 
ozsena is concerned, is the same in signification. If the inflamma- 
tion is not arrested, necrosis or caries, partial or complete, results. 
Soon a discbarge makes its appearance, disgustingly foul if the case 
is one of necrosis, and more or less offensive, and mixed with osseous 
particles, if it is caries. 

Anti-venereal treatment is a treatment of building up. You cannot 
hope to arrest syphilis in any other way, when it has passed to its 
tertiary manifestations. Limit and circumscribe the local inflamma- 
tion as much as you can ; and to do this you will generally find that 
stimulants act a better part than depressants. An excellent medica- 
ment is a combination of iron, iodine, quinine, and glycerine : 

R. — Tincturae ferri chloridi, 5j ; 
Quiniaa sulphatis, gr. xxv ; 
Tinctura? iodinii, 
Glycerines, aa Jj ; 
Aqua?, ^iv. M. 
Sig. — Inject, or brush over and about the parts, three times a day 

Give iron and quinia internally. It is scarcely probable that a 
patient having syphilitic necrosis needs a mercurial course ; indeed, 
it is much more likely that he has already been so over-drugged with 
this medicine that his trouble is mercurio-syphilitic, rather than 
syphilitic alone. Iodide of potassium is recommended and freely 
prescribed in these tertiary conditions ; it may be given in doses of 
from ten to twenty grains dissolved in water or in the fluid extract 
of sarsaparilla. But good rare roast beef, poultry, a daily glass 
of malt liquor, boat-rowing, wrestling, horseback-riding, systematic 
bathing, these are the reliable means, and may elevate the vital 
forces to an ability per vias naturales to throw off the disease. It 
is confessedly hard to cure syphilis when it has fully taken hold of 
the system ; and when it inflames a bone, particularly a small one, 



OZMNA. 655 

the patient is lucky if he escape without the complete destruction 
of the part. 

Necrosis, partial or complete, implies, of course, the existence of 
a sequestrum ; and the getting away of this dead part implies very 
generally the cure of the ozaena. Particularly is this the case when 
the death is limited to the single bone or piece. To get away this 
piece is, then, one of the most important features in the treatment. 
How is it to be done ? Simply wait until the probe reveals that it 
is loose ; if it may not be taken away through the orifice of the sinus 
it has itself created, we have only to enlarge in any convenient man- 
ner such sinus, and then lift the piece away. If, after the removal of 
such dead bone, we find the discharge continuing, but modified as 
to character and odor, we infer the necessity for stimulation, and 
use iodine, or iodine and iron, or the combination with tannin 
and glycerine, as seems to be indicated. It may be, however, that 
neither the discharge nor the odor decreases; in such cases we are 
seldom wrong in inferring that more dead or dying bone is in the 
wound, and the treatment first employed is to be renewed. When 
tertiary syphilis has associated with it severe nocturnal pains, great 
relief is frequently secured from the administration of the iodide of 
potassium, particularly if combined with minute doses of phosphorus, 
— say five drops of the diluted phosphoric acid as a dose ; it is to be 
remembered, however, that, because of the relationship of the potash 
with the mucous membranes, in many persons even very small doses 
will excite much irritability in the air-passages, thus seeming to in- 
crease instead of allaying the trouble. With such patients we must 
diminish the dose of the iodide pro re nata. 

Bromide of potassium is now frequently employed to procure rest 
and tranquillity. It is commonly prescribed in doses of ten grains ; 
but forty or fifty will be found the better dose. It is best given in 
a little water just as the patient is about to get into bed. 

Lodgment and Retention of Foreign Bodies. — In the use of cotton 
or sponge about the nares, care is to be taken that the pellets do not 
escape attention and remain lodged in the passages. Some of the 
most offensive and resisting discharges occasionally have their cause 
in this direction. Rhinolites — calculi varying in size from that of a 
pea to that of a pigeon's egg — sometimes form in the canals, and, by 
inducing ulceration and collectingdetritus, become the source of ozeena. 
Peas, rags, buttons, and sundry other articles are not unfrequently 
found in the nares, thrust there by children of experimental procliv- 
ities : any of which may, of course, become a source of offense. 



656 ORAL DISEASES AND SURGERY. 

The removal of foreign bodies from the nares is always to be ef- 
fected as speedily and with as little injury to the parts as possible. 
A plan that may first be tried is to place the patient in a strong light 
and search the parts with very delicate forceps : if the body can be 
seen, it may thus generally be removed. Another plan consists in 
giving a pinch of snuff and compressing the unobstructed nostril ; 
the effort of sneezing will not unfrequently throw the body a con- 
siderable distance. Still another plan is to compress the unobstructed 
nostril and blow into the mouth, thus forcing it out. An annealed 
wire, bent into the form of a loop and passed over the body, is very 
frequently employed with satisfactory success ; a flexible, blunt, 
double hook is also used with advantage. The syringe is sometimes 
found beneficial, the obstruction being washed back into the throat. 

The convenience of the douche bath in ozsena is found very great. 
Thudichum's apparatus* highly commends itself in such direction. 
Another instrument of great service is the rubber bulb atomizer : 
this is used by the patient without effort or trouble of any kind, 
and carries the spray to every part of the nostril. This little instru- 
ment may be charged with a solution of permanganate of potash or 
with chlorine-water, and kept about the person ready for use at any 
required moment. In cases which emit much fetor, its employment 
will avoid many moments of mortification. 

Syphilitic coryza in infants, characterized by snuffling and difficulty 
in holding the breast, is not unfrequently associated with offensive 
discharge. Here the excessive delicacy of the affected membrane 
is not to be overlooked. While it is a necessity to keep the parts 
well cleansed, it is not permissible to employ any but the gentlest 
means. Borax-water associated with a little glycerine is a nice 
preparation, or a weak solution of the phenate of soda may most 
satisfactorily be used. Fissures of the membrane may be touched 
with dilute chloride of zinc, or with iodine ointment made very 
weak. 

* " Some years ago it was discovered by Professor "Weber, of Halle, that 
when one side of the nasal cavity is entirely filled through one nostril with 
fluid by hydrostatic pressure, while the patient is breathing through the 
mouth, the soft palate completely closes the choanse, and does not permit any 
fluid to pass into the pharynx, while the fluid easily passes into the other 
cavity, mostly round and over the posterior edge of the septum narium, and 
escapes from the other open nostril, after having touched every part of the 
first half of the cavity of the nose, and a great part — certainly the lower and 
median canals — of the second half." — Thudichum : Polypus in the Nose, and 
Ozsena. 



OZJSNA. 657 

The employment of the rhinoscope in rhinorrhcea or ozaena is 
to be commended as of great value in making a diagnosis. Ante- 
rior rhinoscopy is performed most simply by using two delicate 
ivory spatulas and placing the patient in the full sunlight. Or, 
placing his back to a bright gas-flame, a stream of light is thrown 
up the nostril by means of a reflector. A mode of anterior illumi- 
nation frequently employed by the author consists in extending the 
ala, and passing the light through a silvered speculum. 

The nasal speculum of Metz differs from the ivory blades in being 
made of highly-polished metal. A speculum known as Duplay's 
anterior is the analogue of the common bivalve vaginal instrument, 
the valves being separated by means of a screw. 

Posterior rhinoscopy is not so easy and simple of accomplishment : 
indeed, in many cases it is impossible to reap any benefit from it. 
An instrument devised by Dr. Limrock is highly lauded by many 
for its capability in this direction, being provided with a movable 
spatula, which governs the movements of the uvula. A modifica- 
tion of the instrument by Duplay is also before the profession. 
This consists of a glass and delicate hook attached to associated 
shanks, the two separating as do the blades of a pair of scissors. 
The author frequently practices posterior rhinoscopy by placing the 
patient, with widely-opened mouth, in the direct rays of the sun, using 
the square glass, and controlling the uvula with a scalpel-handle.* 

* A most instructive clinical lecture on Khinoscopy, by Dr. Harrison Allen, 
will be found published in the Philadelphia Medical Times for August, 1872, 
to which the reader is referred. 



42 



CHAPTER XXXIII. 

THE ANTRUM OF HIGHMORE, AND ITS DISEASES. , 

Many years spent in a practice which should have afforded every 
opportunity for observation, as well as a scope of view which 
necessarily offers to one who is a frequent visitor at hospitals and 
clinics, combine to impress me with the truthfulness and propriety 
of the conclusion, that the diseases of the antrum are, for the most 
part, simple in character, easy of diagnosis, and, as a rule, not at all 
difficult of treatment. Indeed, I have not unfrequently thought that, 
for the purpose of general study, one would not be entirely without 
justification in asserting that there are but two sources of trouble 
to be found in this cavity : the first, and prominent, being lesions 
secondary to the diseases of the teeth ; the second, the troubles 
common to mucous membranes, wherever situated. 

Certain I am, at any rate, that, without fear of successful contra- 
diction, I may assert that the great majority emanate from the first 
of these directions ; while the atonic conditions, represented by the 
dropsies, the puruloid secretions, the mucous engorgements, and the 
ulcerations, are in no wise different from the ordinary mucoid affec- 
tions, except as modifications may be made by situation, the last 
being conclusively proven, I think, by the fact that what is the cure 
of the one is the cure of the other. 

While thus asserting, however, that in these two directions lie 
the chief sources of trouble, I would not by any means be understood 
as implying that the subject is unworthy of investigation outside of 
such considerations : on the contrary, I am bound to confess that I 
find recorded more than one description of diseases of the cavity, 
which to me, at least, are as anomalous in principle as they are in 
description, and which I can only explain either on the ungenerous 
supposition that the authors must have drawn somewhat on their 
descriptive powers, or else that the antrum has some of the strangest 
anomalies. 

Again, as a class coming between these uncommon and the 
common affections, it follows, not at all indirectly, that there exist 
(658) 



ANTRUM OF HIGHMOKE, AND ITS DISEASES. 659 

sequelas of certain of the exanthemata which have a special and 
peculiar affinity for this cavity ; while, in syphilis, I have seen the 
very first event in the secondary train exhibiting itself in a dis- 
turbance of this sinus. That this latter, however, is rare, I well 
know from observation extending over a great number of cases; 
indeed, syphilitic troubles of the antrum are so infrequent even in 
the tertiary stage of that affection, that observation will lead to the 
inference that the cavity never takes on the disease unless when, from 
continuity of structure, it has the trouble absolutely forced upon it, 
as it were, either from its relationship with the hard palate in the 
oral direction, or with the turbinated bones in the nasal ; for, while 
the practitioner will surely hear complaints, yet, if he investigates 
the cause of trouble, he will find, as I so often have found, that mer- 
curial inflammation of periodonteal membranes is the source of offense, 
rather than the specific condition. Clumsily performed surgical 
operations are also the occasional causes of morbid conditions being 
set up in the cavity, which, when existing, would of course be so 
evident as to force the consideration of them upon the attention, — 
the most common of these being the breaking' of the fangs of teeth 
in attempts to extract these organs. 

With these preliminary remarks, we pass to a consideration of 
the premised principal cause of antral trouble, — diseased teeth. 

In the chapter treating on " Anomalies of Dentition," attention 
was directed to the close relationship of the fangs of several of the 
teeth with the floor of the antrum, and to the fact that it was not 
unfrequent to find these fangs — particularly the palatine of the 
second molar — penetrating the sinus, thus associating their mem- 
branes, and furnishing a continuity of structure. 

In the same chapter attention was also called to such diseases 
and conditions of the alveolar border as were apt secondarily to 
affect the antrum : means of diagnosis and treatment being sug- 
gested. The reader who may feel sufficient interest in the subject 
will do well to review the chapter alluded to, before proceeding to 
the consideration of the clinical cases presented, and which, I 
think, will sufficiently illustrate this department of diseases of the 
antrum. 

Case I. — Indolent Tumor on the Bight Cheek. — A woman had 
an indolent tumor on the right cheek, about the size of a pigeon's 
egg, occasioning much disfigurement, but altering the color of the 
skin very slightly. The patient had often suffered violent tooth- 



660 ORAL DISEASES AND SURGERY. 

ache on this side, and, though young, had few teeth now remaining, 
and these all carious ; otherwise she was in very good health. 
The tumor was prominent toward the cheek, palate, and nostril, 
yielded on pressure, and gave a slight noise as it returned to its 
position. 

These symptoms caused the practitioner to suspect the existence 
of some fluid, which it was necessary to evacuate and follow with 
suitable injections. For this purpose, the cheek was drawn aside, 
and an incision made into the bone above the gum, with a bistoury, 
enlarging it before and backward, till a sufficient opening was ob- 
tained, from which escaped an inodorous mucous fluid. The bone 
was at no point denuded of its periosteum. The wound was dressed 
with a pledget of lint saturated with spirits of wine, and the next 
day the patient was better. On the third day she was feverish, the 
sinus was swollen and painful, and the discharge acrid and fetid. 
These symptoms were controlled by proper remedies, and, after 
twenty-four days, the walls of the sinus were nearly restored to 
their normal condition. 

The canine tooth of this side being very obliquely situated, it was 
thought proper to extract it, and thereupon followed an escape, 
through its socket, of fluid contained in the sinus, though the tooth 
itself seemed perfectly sound. Through this orifice injections were 
made. The opening made in the external wall healed promptly, 
without any exfoliation ; in six months the tumor entirely disap- 
peared, and the patient was cured. (From Baron Haller's " Collec- 
tion of Medico-Chirurgical Theses.") 

The translator of the above case, in commenting upon the treat- 
ment, pointedly remarks, " One cannot fail to see the uncertainty, 
not to say obscurity, of the treatment here adopted. Though all 
the teeth were carious, and their extraction was plainly indicated, 
an incision in the external wall of the antrum, or, more correctly, its 
destruction, was determined upon. The result we see in the symp- 
toms which supervened on the third day, which were, perhaps, 
hastened by the spirits of wine. We have here a canine tooth quite 
displaced and involved in the tumor; yet it was long before the idea 
of its extraction occurred, though the subsequent discharge, through 
its socket, proved how advisable it would have been at the com- 
mencement of the treatment. In this way the time of cure might 
have been shortened by half." 

Case II. — Distention with Softening of the External Walls of 
the Sinus. — "In ," says this same surgeon, "I was consulted in 



ANTRUM OF HIGHMORE, AND ITS DISEASES. 661 

the case of a large tumor of the right cheek. The external wall 
was much distended and softened, and yielded to pressure, upon 
the removal of which it gave a sound resembling the crushing of 
an egg-shell. The nose was turned to one side, — the nostril was 
obstructed, — yet the patient suffered no pain, and the skin, though 
distended, preserved its natural color. On examination of the 
mouth, I found that the crowns of the bicuspidati and molars were 
destroyed by caries, which induced me to advise the extraction of 
their persistent fangs ; the patient consenting, this was immedi- 
ately done. The shock occasioned by the extraction of each of the 
fangs, caused a portion of fluid to escape from the sinus through the 
natural opening: it was thin, reddish, saline, and inodorous, and, 
in all, about three spoonfuls. The tumor could now be made to dis- 
appear by pressure, but would again return to its full size. Pressure 
caused no escape of fluid through the nasal, and but slight through 
the alveolar, opening, which was at the bottom of the first molar 
socket, and large enough to admit the finger. 

" The internal membrane of the sinus was entire, except at the 
alveolar opening: through this I made injections of warm water, 
strengthened with a little alcoholic vulnerary fluid. The next day 
I injected the sinus repeatedly with a decoction of agrimony* and 
honey of roses, meanwhile not neglecting external compression. In 
fifteen days the parts returned to their natural condition, all crepita- 
tion of the bone ceased, and the discharge was very slight. I now 
had recourse to stimulating solutions. On the second day the dis- 
charge had ceased, and the alveolar opening was reduced to a mere 
fissure, and in a month from the extraction of the teeth the patient 
was fully restored." 

Case III. — Periodonteal Abscess affecting the Antrum. — A patient 
was brought to me who, for more than three months, had suffered 
with a tumor like the above, on the right side. The maxillary 
cavity was distended to a level with the orbital margin ; the nose 
was turned to one side, and the vault of the palate was remarkably 
prominent. I removed the fangs of the first two molars, the crowns 
of which had been destroyed by caries, and which I believed to be 
the immediate cause of the disease. I then enlarged the opening at 

* A mild tonic and astringent. An injection of more character would be 
as follows: 

R.— GHycerinse, §j ; 

Tincturse opii camphoratse, 3 ij ; 
Aqua? Colonise, Sfiv. M. 



662 ORAL DISEASES AND SURGERY. 

the bottom of one of the sockets, through which escaped a large 
quantity of a serous inodorous fluid. Pressure upon the palate and 
external wall caused its escape through both the alveolar and the 
nasal opening: this compression, together with suitable injections, 
soon terminated the disease. 

The teeth on the left side being in a similar condition, their re- 
moval was urged ; but to this the patient would not consent. In 
three months she came to me with a precisely similar swelling of 
this side, which, having the same cause, I cured in the same 
manner. 

Case IV. — Abscess of the Antrum caused by a Tooth. — The fol- 
lowing very interesting and instructive case is from the practice of 
Dr. J. D. White, and was reported for the Dental Cosmos by his 
son, Horace Meredith White, M.D. : 

"Mr. S., aged twenty years, light complexion, peculiar whiteness 
of the skin, — a characteristic of the family, — had been complaining 
for some time of a fetid discharge from the right nostril ; of heat, 
and a sense of tension, in the right superior maxilla. 

" He applied to his physician, who gave him a wash, with the 
belief that the parts would speedily return to their normal condition, 
he supposing the affection to be merely an increased discharge de- 
pending on a slight local hypersemia, the result, perhaps, of the bad 
state of the weather at the time. The parts, however, did not re- 
cover; the discharge became much more fetid, and evidently was 
principally composed of unhealthy pus, though it was not as copious 
as it had been previously ; the pain was not severe, but the heat of 
the parts more elevated, and the sense of tension increased. The 
patient was irritable and pale ; the heat of the body was rather 
above the average temperature. This was the condition of the patient 
when he came under the care of Dr. W. 

" Upon examining the anterior naris, nothing could be discovered 
to account for the discharge ; the mucous membrane being a little 
inflamed, but not sufficient to occasion it. A diseased state of the 
antrum was suspected, and the mouth was examined to ascertain if 
a diseased tooth could be the cause. The second molar, upper jaw, 
right side, was unsound. Part of the crown was decayed away; the 
bulbous portion of the nerve, and the filaments of the buccal roots, 
were dead, but that part in the palatine root was living, and occa- 
sioned the patient pain. A little arsenical paste was applied to de- 
stroy it. No sign of alveolar abscess was present in it or any other 
tooth. The next day the nerve in the palatine fang was removed 



ANTRUM OF HIGHMORE, AND ITS DISEASES. 663 

without trouble ; a careful inspection was now made, and important 
information was received. Upon examining the right nostril with 
a speculum, a little pus was seen in the middle meatus. The patient 
was requested to incline the head toward the left side ; he did so, 
and, upon looking at the parts again, a large amount of pus was 
found. This, together with the facts stated already in this paper, 
and that there was no other assignable cause of the discharge, was 
deemed sufficient to establish the diagnosis, — abscess of the antrum, 
caused probably by the unsound second molar tooth. 

" Extraction was advised and submitted to. Upon the removal 
of the tooth no pus escaped. A probe was introduced into the alve- 
olus previously occupied by one of the buccal roots, and readily 
passed on into the antrum ; pus now followed the withdrawal of the 
instrument. 

"The cure was completed on general principles." 

Dr. White concludes the description of his case by remarking a 
coincidence which it will not be at all amiss to repeat here, — a coin- 
cidence which must have been very alarming to the patient. The 
gentleman had repeatedly visited a horse belonging to his father, 
which had a profuse discharge from the nose, thought to be glanders. 
The date of the horse's malady was prior to that of the patient, 
and, of course, the inference as to infection was a very natural one. 

Dropsy of the Antrum. — This, which is only another name for 
mucous engorgement, is not unfrequently, as I have had occasion to 
observe, the result of a reflected chronic periodonteal inflammation. 
In such cases, we have the analogue of similar inflammation in the 
cavity of the mouth : the membrane becomes puffy and thickened, 
the mucous secretions become inspissated, and the natural opening of 
the sinus (simply through this thickening of the mucous membranes, 
the folds of which are the natural outlet of the cavity) becomes ob- 
literated. All egress being closed, the result is not difficult to sur- 
mise : if there should not occur atresia of the occluding membranes, 
and no correct surgical assistance is afforded, there must, of course, 
result either the gradual attenuation of the weakest portion of the 
parietes of the cavity, or the setting up of active and severe inflam- 
mation. If, on the contrary, the natural outlet has a partial restora- 
tion, it is not at all unlikely that a troublesome and, if misunder- 
stood, tedious and unmanageable puruloid discharge will ensue : 
this being the result of a continuance of the cause of trouble. 
Recalling illustrative examples from my own practice, I remember 



664 ORAL DISEASES AND SURGERY. 

particularly the case of a child who, previously to coming under care, 
had been treated nearly two years for the occasional discharge of 
muco-purulent matter from the left nostril ; the child was of bad 
temperament, being a cross of the bilio-lymphatic. This patient I 
had the satisfaction of relieving in a single week, the treatment being 
wholly directed to the dental arch, if I may except a course of salt 
sheet-baths, — continued long after the local cure, and which had been 
directed in consideration of the relaxed condition of her general 
system. 

The relation of temperament and conditions is to be closely con- 
sidered in connection with these diseases of the antrum : it is, of 
course, far from being every one who is troubled with a bad tooth, 
the fangs of which penetrate the cavity, who has secondary disease 
as the result, I have just now under treatment a patient suffering 
from necrosis of the whole roof of the mouth, the result of a syphi- 
litic cachexia, the exciting cause of the local trouble being an incisor 
tooth anomalously developed. This tooth, the extreme point of which 
presented just back of the incisive foramen, had been mistaken by a 
practitioner for the point of a sequestrum, and, being worked and 
cut at, periostitis had developed ; and when the dead bone, which 
is the result, is ready to come away, I am sure I shall find both 
antra exposed.* 

Without such predisposing cause, it is evident, this extensive dis- 
ease would never have been excited. It is the same as in every 
other direction of surgical practice: one man receives a wound, a 
cut perhaps on the face, and it troubles him so little that he scarcely 
stops for a moment to examine the injury ; another receives pre- 
cisely the same kind of a wound, and in a week is dead from 
erysipelas. 

A purulent condition of the secretions of the antrum may be 
viewed as one would view a gonorrhoea ; indeed, Mr. Bell, the 
English author, describes the conditions as being similar, "both 
diseases," he says, " consisting equally of an altered secretion, — in 
the one, of the pituitary membrane, and in the other, of the muscular 
lining of the urethra, which in neither instance possesses any of 
the characteristics of abscess, though the matter in both is purulent.'- 

Certainly, if we allow for some differences, as influenced by cause 
and location, the description of the one would very well answer as 

* This proved to be the case, the lost process being now replaced by an 
obturator. For the making of such an instrument, see " Palatine Defects." 



AXTRUM OF HIGHMORE, AND ITS DISEASES. 665 

the description of the other. In both we have the same perverted 
secretion, the same molecular change, the same sthenic and asthenic 
modifications. 

As a gonorrhceal discharge is always preceded by certain inflam- 
matory conditions, and as, after the subsidence of the acute attack, 
the discharge may long continue profuse, or, on the contrary, may 
decline to a scarcely perceptible minimum, so, in antral purulency, 
must we have the associated inflammation, and may have the pro- 
fuse or limited secretion. 

In antral diseases, however, as may be readily inferred, very much 
depends on the nature and associations of the secretion. A profuse 
discharge, with closure of the orifice of the cavity, must necessarily 
entail the most untoward consequences: the walls of the cavity will 
attenuate until (unless surgically relieved) the weakest point will 
give way, the rupture being most apt to occur either within the 
orbit or the mouth. Not unfrequently, however, this weakest por- 
tion seems to be the canine fossa; the opening has also occurred at 
the tuberosity. My own experience would lead to the inference 
that the hard palate is by far the most common point at which the 
matter seeks egress. You will see a tumor bulging out from one 
side of the mesial line, and which advances more or less rapidly, 
until fluctuation becomes very distinct. A sign diagnostic of this 
class of tumors is, that its internal boundary is apt to be quite 
abrupt, and does not pass the line midway to the mesial division. 
The establishment of a fistula relieves it at once of the sense of 
distention, and, if it has formed in a convenient place, as within the 
mouth, the patient may feel disposed to congratulate himself on 
having come to a sufficient cure. Unfortunately, however, in the 
majority of cases, this satisfaction is of short continuance; for, inde- 
pendently of the fact that the disease at once takes on the chronic 
form, making the sufferer an object of disgust to those with whom 
he is brought into immediate contact, — the fetor of the discharge, 
under some circumstances, being really unbearable, — the undue re- 
tention of the secretion within the cavity is a source of such irrita- 
tion to the parts that not unfrequently the most serious lesions 
result. In some instances — happily, rare — all the bones of the face 
are destroyed. 

The causes influencing retention of these secretions are twofold : 
First, the external wound is apt to heal, and to continue impervious 
until an increase of the secretion induces sufficient pressure to cause 



Q6Q ORAL DISEASES AND SURGERY. 

its absorption, as in any case of abscess. In the second place, the 
passage is blocked up by flocculi within the cavity. 

Purnloid secretion in the antrum may, from the onset, be of so 
limited a character that, like secretions in certain of the ovarian 
cysts, years may pass before marked inconvenience results. I am 
acquainted with a case, that of Mr. C, late an eminent merchant of 
this city, in whom, after five years of great mental and physical 
suffering, a disease of the antrum, supposed to be malignant, w T as 
found to be nothing but simple muco-puruloid engorgement depend- 
ing upon a dead tooth. In this case the trouble had commenced 
with a feeling of heaviness and oppression in the body of the jaw ; 
the parts had gradually enlarged until finally there was distention 
of the cheek to the size of a large fist, the eye being thrown entirely 
out of position from the rising of the roof of the antrum. Much 
treatment had been given the case, without the slightest benefit 
accruing. No attention, however, had been directed to the dental 
arch, — the teeth, although the patient was sixty years of age, being 
apparently in the most perfect condition. 

The result of this case was the diagnosis, on the part of a surgeon 
to w 7 hom he finally applied, of a dead nerve in one of the bicuspid 
teeth. The organ, although as healthy-looking as any of its fellows, 
responded to the stroke of an instrument in the manner described 
in the chapter on alveolar abscess ; this tooth was extracted, and in 
six months the health of the patient was perfectly restored. 

A circumstance connected with the extraction of the tooth in this 
case offers an example of practice of which it is well not to lose 
sight. The practitioner who related to me the circumstance, informed 
me that he expected to find associated with the tooth-fang a pyo- 
genic membrane, and to have the extraction followed by a gush of 
pus, in both of which expectations, however, he was disappointed. 
The fang was clean, and the blood which followed the operation 
had nothing peculiar about it. Not to be thus balked, he passed a 
probe up the alveolus of the extracted tooth, which, meeting a 
resisting yet yielding body, he punctured in the direction of the 
antrum ; the withdrawal was followed by a profuse purulent dis- 
charge. This resisting body may be simply flocculi, as alluded to, 
or it may be the mucous membrane proper to the parts : most likely 
it would be found the latter, for we are to remember that it is not 
alveolar or antral abscess with which, in these cases, we are deal- 
ing, but simply what might be termed a mucitis, and, of course, a 
break in the continuity of the membrane is not necessarily to be 



ANTRUM OF HIGHMORE, AND ITS DISEASES. 667 

looked for. The practitioner, in this case, only approximated to the 
exact condition; he thought, evidently, that the trouble was tooth- 
abscess discharging itself into the sinus, whereas (while the treat- 
ment was perfectly adapted to the requirements) the case was one 
of simple mucous or muco-puruloid engorgement, the result of re- 
flected irritation. 

The diagnosis of mucoid and puruloid engorgement of the antrum 
is, as a rule, not difficult to make out. At first there is inflamma- 
tion, and this, as suggested, is found most likely to have origin 
about the teeth. As the trouble advances, the patient begins to 
complain of a sense of heaviness about the body of the cheek. If 
the secretion is active, there will be much pain, sometimes sharp in 
character, but more frequently heavy and unbearably dull. In all 
chronic periodonteal inflammation we have this same dull pain, but 
then it differs from the pain of engorgement in being confined to the 
alveolar arch ; in this latter trouble the greatest pain is found, I 
think, associated with the floor of the orbit, which, as will be remem- 
bered, makes the roof of the antrum. At length, as the secretions 
accumulate, the parietes of the cavity begin to attenuate and expand. 
The tumor now forming may be distinguished from others, — first, 
by the history of the case ; second, by dryness of the naris of the 
affected side, the result of the closure of the orifice of the antrum ; 
third, by the gradual and regular enlargement; fourth, by the non- 
association of the integuments of the cheek; and, fifth, by the fluc- 
tuation which it will finally yield. 

To treat successfully such a trouble, we have only to search out 
the source of offense, and, where it is possible, remove it. If this 
should prove to be a tooth, we may, if necessary, secondarily treat 
the antrum through the alveolus. Where the trouble is thus of 
strictly local origin, we shall find that we need to do very little 
more than employ daily some stimulating injection, such as diluted 
tincture of iodine. Where the acrid character of the retained secre- 
tion has provoked degenerating ulcers, I have obtained the very 
happiest effects from weak injections of chloride of zinc. 

If, on the contrary, such bad conditions of the antrum be associ- 
ated with constitutional causes, I need not suggest that such causes 
must have our attention. In these latter cases, however, where the 
cure promises to be tardy, we may give to a patient complete relief, 
locally, by making an opeuing into the cavity, and keeping it patu- 
lous by means of a cotton tent; this, combined with the daily em- 



668 ORAL DISEASES AND SURGERY. 

ployment of such injections as may seem indicated, will be found to 
yield decided benefit. 

Concerning abscess proper of the antrum, I think it may be set 
down as the rarest of rare diseases. Bell and Bordenhave each 
mention a case. Abscesses, described so frequently as occurring in 
this cavity, will, I think, commonly be found to have their origin in 
the alveolar border, and if treated like any ordinary case of alveolar 
abscess, will generally at once succumb. (See Alveolar Abscess, and 
Anomalies of Dentition.') 

"While," says Dr. Richardson, "we cannot trace out the nature 
of that condition of the blood which gives rise to purulent forma- 
tions, we are informed by observation of the external conditions 
which foster it. We learn that the pus-producing disposition is an 
indication of deterioration of blood. We see that when the system 
is enfeebled, whether by diathesis hereditarily supplied, as by the 
strumous diathesis, — whether by epidemic influences, or whether by 
deprivation of nitrogenous food, or the inhalation of bad air, — that 
under these circumstances the tendency to purulent formations in 
local structures is marked, and that, in extreme instances of the kind 
named, the act of suppuration may take its absolute origin from 
blood thus depressed. 

" Hence we have reduced almost to a principle in medicine the 
saying that suppurative tendency is a sign of an impaired or vitiated 
nutrition. Hence, also, we reason in speculative argument, that 
pus is blood transformed into a lower form of organization, and we 
adduce, in evidence of this view, that the purulent fluid is incapable 
of organic construction, and that in animals in which the respiration, 
the circulation, and the animal temperature are more than ordinarily 
active, the formation of pus, even in an open wound, is an occur- 
rence almost unknown." 

These remarks, from the lectures of Dr. Richardson, cannot fail 
to be suggestive; they have indeed much meaning; but I must 
be permitted to remind the student reader, at least, that their sig- 
nification is limited. Puruloid conditions are, without doubt, and 
as the rule, perhaps, indications of asthenia; but it would be very 
wrong indeed to jump from such data to the conclusion that every 
puruloid disease requires treatment from the constitutional stand- 
point ; and particularly will this hold good as the diseases of the 
antrum are concerned. 

All diseases should be treated on principle. M. Ricord, as many 



ANTRUM OF HIGHMORE, AND ITS DISEASES. 669 

of my readers will remember, has a favorite prescription for gonor- 
rhoeal purulency, which runs as follows : 

R. — Pulveris cubebae, jfvj ; 

Ferri carbonatis, ^iij. M. 

Xow, anybody can understand that such a combination would 
naturally act well on a debilitated system ; and I should sup- 
pose it would be a most happy prescription for half the roues of 
Paris. Where applicable, it would answer as well for the puruloid 
antrum. I remember, during- the past summer, treating a gentleman 
for a gonorrhceal difficulty, which he had contracted almost immedi- 
ately after my getting him over an attack of syphilis. I treated this 
patient locally over six weeks, the discharge constantly increasing 
in quantity. At the expiration of this period I put him upon co- 
paiba, tincture of iron, and quinia, and sent him to the seaside for a 
few weeks. The discharge at once began to diminish, and after the 
eighth day disappeared entirely. A success of this kind would not, 
however, lead to the inference that every man afflicted with a puru- 
lent discharge should be treated with tonic stimulants. On the 
contrary, though I have had the opportunity of prescribing very fre- 
quently for this condition, — gonorrhoea, — yet it is seldom that indi- 
cations have seemed to me to call for anything more than a strictly 
local treatment ; at any rate, I have generally succeeded, happily 
and quickly, in getting the patients over their trouble. 

On a previous page it was suggested that puruloid conditions of 
the antrum had origin chiefly from two directions : first, from dis- 
eased teeth ; second, from constitutional disturbance, manifesting 
itself in the mucous tissue. It was also desired to convey the infer- 
ence that where the fault was markedly in the first of these direc- 
tions, the practitioner would err on the right side if, in his first con- 
sideration of the case, he should incline to look upon the tooth only 
in the light of an exciting cause, searching farther for what might 
be a predisposing condition. It is, however, to be inferred that 
lesions of the cavity may exist, and yet constitutional conditions 
have really nothing to do with them, and in the treatment need not 
be taken into the account. 

As a line in practice, however, running between these two con- 
ditions, I may allude to the fact that I have met cases where infer- 
ence of constitutional association seemed most marked, and yet have 
soon cured my patients without a resort to other than local treatment. 



670 ORAL DISEASES AND SURGERY. 

These are the kind of cases in which the medical man must feel his 
way : if he be an observer, it is not likely that more than a week 
will pass without yielding him just conclusions. 

Coming now to the investigation of cases where the cause is to 
be found alone in some cachexia, we have only to refer back to the 
general features of disease as manifested on mucous membranes. 

The most common, and indeed not very unfrequent, cause of en- 
gorgement of the antrum — particularly mucous engorgement — is 
simple catarrh of the Schneiderian membrane. The patient takes 
a cold, the excitement expends itself about the nares ; by simple 
continuity of structure the lining membrane of the sinus becomes 
vascularly excited ; perhaps the duplication at the orifice, because 
of greater nearness to the central ring of inflammation, becomes con- 
gested to such extent as to close the opening: thus we have the 
elements for engorgement, and the mucus thus confined will, if not 
vented, sooner or later act as such a source of irritation that it will 
become to the membrane of the cavity almost precisely what the 
virus of gonorrhoea becomes to the same character of membrane 
lining the urethra. Trouble from this cause is, however, generally 
so slight and so quickly over that it is seldom prominently marked, 
either to patient or practitioner. 

The symptoms designating this condition are, first, simple vascu- 
lar excitement of the membrane lining the nares, accompanied with 
increase of mucus. 

As the grade of inflammatory action advances to complete con- 
gestion, the excess of mucus associated with the immediately pre- 
ceding stage is succeeded by a most uncomfortable deficiency in the 
secretion. 

This dryness is associated with all nasal inflammations of ad- 
vanced grade, but when the trouble is to implicate the antrum it is 
even specially marked. A single moment's consideration of the 
parts makes this very plain : the nares are the natural outlets for 
the antral secretions ; in ordinary Schneiderian catarrh the extensive 
secretory surfaces of the antra are comparatively unaffected : of 
course they serve to lubricate, to a greater or less extent, the pass- 
ages. When, however, the grade of inflammation is of sufficient 
extent to congest the duplicatures of membrane which form the 
nasal outlets, then, because of the retention of the mucus, the ex- 
treme dryness is induced. This excessive dryness may be said, 
therefore, to offer the first diagnostic sign of antral engorgement 
from simple catarrh. From this point the disease advances or de- 



ANTRUM OF RIGHMOBE, AND ITS DISEASES.' 671 

clines. If it declines, the trouble may have proved of such trifling 
inconvenience as scarcely to have attracted the attention of prac- 
titioner or patient. If, on the contrary, it advances, the patient 
will soon be made conscious of the engorgement by a sense of 
growing heaviness in the cheek, attended by pain of a dull, slug- 
gish character. The progress of the disease, from this condition, 
is precisely the same as that described as accruing from dental 
troubles. 

Treatment. — This is to be conducted on general principles. 
Where the disease is seen in its incipient stage, it will, perhaps, be 
found unnecessary to do more than administer a saline cathartic; or, 
what I have found a most satisfactory treatment is to administer to 
the patient at bedtime one-sixth or one-quarter of a grain of sulphate 
of morphia dissolved in an ounee of the liquor ammonise acetatis. 
This latter treatment will seldom be found to fail in breaking up 
these limited congestions. 

Where, however, the disease has advanced to engorgement, and 
the antrum is found to be enlarging, it may be necessary, in order 
to insure against even more serious lesions, that treatment shall be 
directed immediately to the cavity. To accomplish this, extract 
the second molar tooth, and penetrate the cavity through the 
alveolus of the palatine fang ; in this way such medication as may 
seem indicated may be readily employed. Indeed, for a cure it may 
be only necessary to keep the wound patulous, leaving the rest to 
nature, or, if there should seem a lack of vital force, I do not 
think a much happier stimulant can be employed than the tincture 
of iodine before recommended. 

Furuncular Epidemics. — It will be found, I think, the conclusion 
of every one who has observed in the direction, that during the ex- 
istence of furuncular epidemics, mucous and purulent engorgements 
of the antrum are more than usually common. This is not strange, 
if we consider the epidemic condition in the light of an exciting 
cause alone ; for in no single instance where my attention has been 
called in such direction have I been unable to discover a predis- 
posing cause in a dead or diseased tooth. The same condition of 
things exists in regions where the intermittents are endemic. All 
the odontalgias and cephalalgias of such a country are apt to be 
quotidian, tertian, or quartan. Furuncle is a condition associated, 
it would seem, with some derangement of the digestive or cutaneous 
functions. When epidemic, it would be in proof that a condition 
existed adverse to the performance of certain physiological functions. 



672 • ORAL DISEASES AND SURGERY. 

With the existence of a predisposing cause of disease about the 
antrum, it is not at all strange that the addition thereto of an ex- 
citing cause should at once increase the effect of the irritant even to 
the production of active disease : and such, in truth, is the case : 
the patient escapes the purulency of boils, but he has purulency of 
the antrum. 

Treatment. — This I need scarcely refer to : it consists, first, 
in removing the source of local irritation ; secondly, in correcting 
the constitutional disturbances. 

Scorbutus. — This diathesis, as may be inferred, predisposes to 
antral purulency and ulceration. To understand the local condition 
thus induced, it would be only necessary to examine the gums in an 
individual so afflicted : the condition of the antrum is akin to the 
condition of the mouth. The treatment, to be successful, must be 
from the constitutional stand-point. If injection of the cavity seems 
indicated, it must be gotten at as before directed, or a canula can be 
passed into it through the natural opening in the middle meatus : 
the latter is, however, difficult, and therefore liable to objection. 

The Exanthemata are said to associate, not unfrequently, their 
sequela? with this cavity. Treatment thus demanded could need no 
special consideration : it would be a treatment founded on general 
principles. 

TJie Mercurial Diathesis. — I have before referred to the troubles 
of the cavity thus provoked. Mercury holds a double pathological 
relation to the antrum ; it predisposes from its constitutional rela- 
tions, and actively and locally excites, through the periosteal inflam- 
mation it excites in the alveoli of the teeth. (The same I should 
also have remarked of scurvy.) 

Treatment. — The indications here are twofold. Resolve, if pos- 
sible, the inflammation about the teeth (see chapter on Alveolar 
Abscess), and eliminate the mercury from the S} r stem. The chlorate 
of potash and the common muriate of soda are valuable medicines 
in this direction : the latter I frequently employ, and with marked 
success. 

Syphilis. — This is a disease which it might be inferred would, of 
course, have an affinity for such mucus-lined surfaces as the antrum. 
Now, mine may be a singular experience, but, in contradiction of 
many authors who have written on the subject, I must say that, 
with the wide scope afforded by such hospitals as that of the Uni- 
versity of Pennsylvania, and of Blockley (in which latter, for over 
a year, I gave the study of the venereal disease the closest attention), 






AXTRU3I OF HIGHMORE, AND ITS DISEASES. 673 

I was unable to find a single case of diseased antrum which could 
with justice be attributed to the vice. As remarked on a previous 
page, cases have been met with where the origin has been traced in 
such a direction ; and I will not deny that, in some cases, this origin 
may be justly so traced ; but, in every example that I have seen, 
the mercury administered for the cure of the syphilis has seemed to 
me to have much more to do with the condition than any dyscrasia 
induced by the virus. 

Among what might be termed the anomalous cases of antral dis- 
ease, mention may be made with benefit, perhaps, of a case pre- 
sented at my clinic, November 4, 1871, being a patient under the 
charge of Dr. Cruise. 

Patient, infant, two weeks old. One week after birth the atten- 
tion of the mother was first called to an uncommon restlessness, 
which, however, was quickly found associated with a growing swell- 
ing of the right side of the face, the eyelid being soon closed from 
oedema. Examining the case closely, discovery was made of a dis- 
tending antrum, every portion of the common wall gradually bulging. 
Pressure upon the roof of the mouth, with counter-support to the 
cheek, caused a slight ejection of bloody pus from the nose. A 
diagnosis secured, a bistoury was passed through the attenuated, 
softened wall of the canine fossa, the withdrawal of the blade being 
attended by much pus and blood. 

The treatment of the case, continued by Dr. Cruise, consisted in 
the frequent injection, of black tea, of a strength as prepared for the 
table. Several spiculse of bone came away, leaving the little patient, 
after two or three weeks, in what might be termed a common state 
of health. No injury was known to have happened this child in its 
passage through the pelvic straits. The mother was quite hearty ; 
the father, however, was scrofulous. Three still-births had preceded 
the present child. 

Cases of what may be termed mechanical disease of the antrum 
wall be encountered by every surgeon in the persons of those who, 
having met with the accident of limited exposure of the cavity, are 
in the habit of wearing plugs of cotton, wax, or wood in the break, 
which plugs escape into the cavity. The treatment required is, of 
course, the simple one of getting away the foreign body, — a matter, 
however, not always easy to accomplish. 

43 



CHAPTER XXXI Y. 

THE APHTHAE. 

Aphthae is a term which every reader must have remarked to be 
associated (like the word epulis) with some degree of confusion. 

In the Greek, from which the term is derived, there are two 
verbs with the same spelling, — a-rcu. The meaning of the one is 
" to set on fire ;" that of the other, to " bind to" or to " fasten upon." 

The mouth presents ulcers or sores of various signification, — 
some which are characterized by pain of a burning, inflammatory 
character ; others, chronic, or cold in nature, furnish an inviting 
soil to a very persistent and almost omnipresent parasite, — the 
oidium, — this fungus fastening upon and binding such sores in its 
necklace-like embrace. It has thus very naturally occurred that 
pathologists, seeking an expressive term by which to designate 
these varying conditions, differently employed the common name as 
it happened to them to observe or adopt the one or the other of the 
roots from which the expressions were derived. That such uses of 
the dissimilar verbs on the part of various authors must have been 
made, is necessary to be inferred to explain the differences which 
characterize their descriptions. 

With such examples of liberty, intentional or unintentional, I may 
be excused in presenting to my readers the subject after my own 
manner and views. 

For the reasons of the double derivation, and for others which I 
shall proceed to present, the term aphthae cannot, in justice and 
pathological signification, be applied to a particular species of sore, 
but must, as a noun of multitude, apply to a class, — which class has 
many species. Thus we may accept as explained and dismissed the 
various questions of ulceration and non-ulceration, exudation or non- 
exudation, the oidium or no fungi. 

The type of the aphthae is as follows : An aphtha or aphthous 
patch is a degenerate sore, to be seen, under varying circumstances, 
upon the mucous surface of the mouth, the fauces, the oesophagus, and, 
(674) 



THE APHTHA. 675 

quite likely, upon any part of the alimentary canal, and perhaps 
also the respiratory tract. The most common seat of this patch is 
the uvula ; next to this the lower lip ; next the tongue. The sore 
varies in size, from the smallest point to a confluent mass which may 
cover a large surface ; looks pasty or exudative, is generally oblong 
in shape, and varies in color from the misty white of hoar-frost to the 
dirty yellow of scrofulous pus. As most frequently seen, such a patch 
is one of perhaps several similar sores. 

This, as described, is the typical case. From it we are prepared 
to pass to the general view of the subject. 

An aphtha is a canker; nothing more, nothing less. Thrush, fol- 
licular inflammation, cancrum oris, gangraena oris, are all species of 
a cancroid class, of the class aphthae. 

What, then, is aphthae ?* 

The modern microscopist exhibits and describes aphthae as patches 
of a fungoid excrescence, — the oidium albicans. A pot of paste, a 
papered wall, a section of apple or other fruit, the leather back of a 
book or chair, exposed to a confined atmosphere, hot and moist, 
quickly produces, or rather gives attachment to, the oidium. 

Oidium albicans is not a disease, is not aphthae; neither is it the 
expression of disease. It is merely a fungous growth, accidentally 
associated with a soil and circumstances favorable to it as a habitat.*)* 

Aphthae is, without doubt, the expression of a cachexia, and is 
not likely to be a merely local disease. Neither, I conceive, is it 

* The term is here employed as a noun of multitude. 

f Parasitic fungi (Hogg on the Microscope) — vegetable blights, as they are 
commonly called — have of late years become objects of earnest attention, on 
account of the enormous damage done to our growing crops, and also of the 
many curious facts in their history which have been brought to light. 
Oidium is a common mildew. 

It appears that at particular periods of the year the atmosphere is, so to 
speak, more fully charged with the various spores of fungi than it is at others. 
In 1854, the Eev. Lord Godolphin Osborne, during the cholera visitation, 
exposed prepared slips of glass over cesspools, gully-holes, etc. near the dwell- 
ings where the disease appeared, and caught what he termed aerozoa, — 
chiefly minute spores and germs of fungi. 

From this same year (1854) to the present time, we have amused ourselves 
by catching these floating atoms, and, so far as we can judge, they are found 
everywhere, and in and on every conceivable thing, if we onl}- look closely 
enough for them. Even the open mouth is an excellent trap. Of this there 
is ample evidence, since we find on the delicate membrane lining the mouth 
of the sucking, crying infant, and on the diphtheritic sore-throat of the adult, 
the destructive plant oidium albicans. 



676 ORAL DISEASES AND SURGERY. 

possible for the fungus to be peculiar to a sore, as a something 
specific, any more than it is peculiar to the paste, the fruit, or the 
book. It must depend in the one instance, as in the other, upon an 
accidental association. This accident, in the case of the sore, would 
seem to be the absence of a sufficient vitality to enable a part to 
resist the " fastening upon itself of ever-present parasites. The 
microscopist, if I may be allowed to suggest it, has, in his examina- 
tions and conclusions, accepted the accident and overlooked the 
disease. 

Thrush or muguet, one of the species, is an erythematic inflamma- 
tion, degenerating after a few clays into a condition of curdy exuda- 
tion. The inflamed surface, after a longer or shorter time, presents 
small whitish points ; these coalesce, forming the exudate patches. 
These patches vary in color: as they remain moist and clear, they 
are considered with least apprehension ; as they grow dry and 
brown, they are esteemed possessed of dangerous import. 

Dissections of the cadaver have exhibited aphthae not only upon 
the oesophageal mucous membrane, but also on other parts of the 
alimentary canal. They have not as yet, so far as I am aware, been 
met with upon the respiratory tract ; but there is no good reason 
why they should not have here a like existence. 

In an acute attack of thrush, the mouth is hot and the general 
condition feverish. Milder cases, or those of easy progress, may, 
and do, seem — so far as any observable constitutional sympathy is 
concerned — to have only a local signification. 

But, if thrush is a distinct disease, could it be possessed of a 
double signification ? Could it at one time be strictly local, at 
another systemic? Thrush is common to children prematurel}' 
born or to those nursed by unhealthy women. It is a disease which 
belongs to hot, moist climates, to the situations of uncleanly hos- 
pitals ; in fact, to any condition recognized to be depressive of the 
life-force ; it is, in short, a systemic adynamic expression, seated on 
a mucous surface. That it differs from carbuncle or cancrum oris 
would not seem to be the case in fact, but only in degree. Thrush 
is, in other words, one expression of a common condition, — a species, 
not a class. 

Follicular inflammation — another form of stomatitis very likely 
to be asthenic — is a term used to signify that the abnormal vascu- 
lar change is seated in the mucous crypts or follicles. In passing 
the finger over a surface so inflamed, the studded irregularity pro- 
duced by the engorgement of the glands is plainly evident. As 



THE APHTHAE. 677 

such inflammation progresses, the bodies become recognized by the 
eye as papular eminences standing out from a common erythematic 
surface. In color they are of a varying red, such variations in shade 
expressing the constitutional conditions. 

Follicular inflammation terminates either by resolution or ulcera- 
tion : when in the latter way, the follicles soften in the centre, sup- 
purate, and have the bottom filled with a whitish, pasty mass; when 
in this condition, they are the aphthae of M. Billard. 

Follicular inflammation appears most frequently in the infant 
during the dentitional period, — an explanation existing in a quickly 
and easily recognized combination of a predisposition and an exci- 
tant. In its most simple form, — that is, where there is no marked 
d} T scrasia, or where the excitant is not of sufficient intensity to irri- 
tate to any extent, — the lancing of the gums, or the application of 
cooling local remedies, may be sufficient to combat or control the 
manifestations. Where, on the other hand, the conditions predis- 
posing to the disease exist in a state of balance, as it were, with the 
natural resistive forces, the addition of a second depressant influ- 
ence, as that resulting from the irritation of dental development, 
may very well be understood as giving the mastery to an agent or 
condition otherwise controlled or held fully in check. Thus we 
explain to ourselves the real and apparent connection of dental irri- 
tation with the aphthae. 

From a simple form, or the inflammation of isolated follicles, the 
condition, in some ill states of the general system, becomes conflu- 
ent, such extreme form being most frequently noticed in the typhoid 
exanthems, or in destructive organic diseases In confluent follicu- 
lar inflammation, a prognosis can only be justly made when every 
associate and collateral influence has been appreciated. The condi- 
tion will nearly always be found an occasion for anxiety. 

Cancrum oris, a species of stomatitis, generally accorded a special 
classification, differs in no wise from that just considered, except in 
being more localized, as if the force of an influence had concentrated 
rather than diffused itself. 

The complaint known as cancrum oris is an asthenic spreading 
ulcer. In appearance this ulcer differs from what has been given 
the special definition of aphthae by most writers, only in being more 
depraved and threatening. It has the same pasty bottom of vary- 
ing shades of white, the same association of pain, the same variation 
in persistence. Like other aphthae, cancrum oris seems to be, and is, 
associated with dyscrasia, appearing most commonly in the infants 



678 ORAL DISEASES AND SURGERY. 

of ill-conditioned charities, in the ill housed and poorly fed, — having, 
in all systemic associations, the precise history of the species alluded 
to as thrush and glandular inflammation. 

This form of stomatitis, although confined to no exact locality, is 
yet most commonly met with on the cheeks or gums. It may com- 
mence with a phagedenic impression, and very quickly destroy the 
patient ; or a slight vesicle or pustule may first appear, to be fol- 
lowed by varying inflammatory associations, precisely as if some 
local poison was the source of the trouble. 

The history of cancrum oris differs from that of other cancroid 
affections only in degree. This is fully proven in the facts that it is 
associated with the same causes ; that any ordinary canker sore is 
capable of taking on an ulcerative action ; that the fungus oidium is 
quite as common to the seat of this as the other affections. In fact, 
every analogy will demonstrate that the relation is like that which 
associates the phagedenic with the simple venereal sore, being the 
difference of degree and not of cause or character. 

Gangrasna oris, sloughing phagedena, is another expression or 
species of the common class. It may commence as an acute inflam- 
mation, quickly deteriorating ; as a species of fatty degeneration of 
the epithelial tissue ; as a submucous effusion ; or as an eschar which 
falls from its relations with a rapidity that leaves us at a loss for 
an explanation, except on the inference that the materies morbi have 
had the most special concentration. The eschar, formed sooner or 
later, is ashy in color, or a deadish brown, while the still living 
parts, particularly the external cheek, if this part should be the seat 
of the ulcer, has an erysipelatous blush, — white, semi-livid, and 
threatening in appearance. 

Gangraena oris is markedly a disease of the dentitional period, 
occurring in ill-fed, ill-clothed, or ill-housed children, between the 
first and second dentitions. Most conspicuous is the constitutional 
nature of this affection. It is, it seems to me, a general febrile or 
inflammatory disturbance, concentrating its greatest force upon some 
part of the oral cavity, invited or directed, without doubt, by the 
irritability therein existing, — proof of which inference lies in the 
fact that in nearly every case we find inflammatory complications, 
such associated inflammations being most frequently found in the 
lung-tissue. I take it for granted that the oral concentration saves 
some other more important part. 

Gangraena oris, where it does not too quickly kill and separate 
its eschar, affords support to parasitic fungi ; the oidium albicans, 



THE APHTHM. 679 

as in the other forms of aphthae*, being that most frequently met 
with. 

Oral gangrene varies, as would be inferred, in degree : thus, com- 
mencing as a single canker sore, or epithelial degeneration, and 
terminating with no very serious result, it might be described as the 
follicular, or other of the simple species. Concentrated, or in its 
malignant, form, it destroys life without affording the physician 
anj" extended chance to combat it. In reasonably healthy children 
gangrene is very uncommon, the ordinary canker being generally 
the worst manifestation. In children exhausted under the exan- 
thems, in those maltreated with mercury, or those laboring under a 
syphilitic degeneration, the marked or destructive type is exhibited. 

The decomposition of mucus, or the debris remaining from the 
food, when lodged upon an aphthous sore, forms the best nidus for 
the development of fungi ; it is, as it were, a soil ; and it is unde- 
niable that epithelial scales in varying states of abnormal degenera- 
tion, inspissated mucus, and particles of decomposed food are general 
to all such sores. Thus, in sickly children, the fungoid association 
is most common from the fact of the weakened energy of the parts 
afflicted ; this favoring decomposition and the retention of the debris 
in the cavity of the mouth, and consequently producing the required 
soil or habitat of the oidium, as alluded to. 

In foundling-hospitals, where the sucking-bottle is used, the spores 
of fungus find, through such vehicle, an easy passage to the mouth, 
being in this way located and developed. In the nursing infant of 
an uncleanly mother, the accumulation and retention of the milk will, 
with favoring atmospheric influences, quickly develop fungi. It is 
the fungus and not aphthae that is contagious, as must be plainly 
seen ; hence one can but wonder at the disputes of Guersant, 
Billard, Valleix, Duges, and others. 

Review. — Having thus expressed my own views of aphthae, com- 
mitting myself to the admission that I fail to distinguish it as any 
special disease, I may, with perhaps greater justice to the subject, 
present the opinions of others whose extended observations and 
judgment have long held them in the light and position of authority. 
Trousseau and Delpech both describe the aphthae as being sores 
with the materies morbi deposited beneath the epithelium. Bam- 
berger (Krankheiten der Mund unci Mundhohle) controverts these 
views, and explains the presence of the soormasse by the fact that 
it has insinuated itself between, among, and below the epithelial 
particles. 



680 ORAL DISEASES AND SURGERY. 

"If we take," says Professor Bamberger, "the soormasse, and place 
it under the microscope, we find it made up almost exclusively of 
epithelial scales, old and young, the debris of the food, and of in- 
spissated mucus, which last is probably only a condition of epithe- 
lial formation. The color of the mass is not to be hastily judged, 
as this might have been influenced by the debris of the mouth. 

"Upon these sores, however, very quickly appears a peculiar 
organization, which consists of round and oval spores which stick 
to each other, and in this way form a more or less ramifying series 
of threads. The longer the sore continues, the more marked is its 
penetration by these threads or spores. This new organization, or 
fungus, can never, however, originate or be generated by the organ- 
ism itself, but is always the result of germs coming from outside 
sources. It is not peculiar to a particular sore, though it occurs 
most frequently on those of a certain order. Besides the two con- 
stituent parts, epithelial scales and fungus, there appears sometimes 
a third constituent, in the form of granules or granulated matter. 

" From this," continues Professor Bamberger, " we see that aphthae 
cannot be counted among the products of inflammational and exuda- 
tional processes, as so frequently considered ; the microscope has 
failed to discover an exudational appearance : also there are wanting 
the anatomical and clinical appearances of inflammation. True, it 
may be that it is found in association with a catarrh, but this is an 
accident, just as one may not sav- that the diarrhoea so frequently 
found in connection with the sore in the infant is the cause of the 
sore, as he might not say that the sore is the cause of the diarrhoea. 
There is, in aphthae, no ulceration, the soormasse being capable of 
being peeled from the surface." 

Professor Dewees thus refers to the aphthae as exhibited in the 
infant : 

"This complaint is generally called the baby's sore-mouth: it 
consists of a greater or less number of white vesicles on the inside 
of the mouth. It very generally begins on the inner part of the 
lower lip, or corners of the mouth, and much resembles a small 
coagulum of milk. From this point it sometimes spreads itself very 
rapidly over the inside of the cheeks, tongue, and gums ; and, at 
others, it will appear in the same form, and at the same time, on 
several portions of the mouth; as inner portions of the cheeks, etc. 
The French, especially M. Billard, make it a different disease from 
what they term 'muguet.' But, from a careful examination of the 
two diseases, I believe them to be the same, differing only in in- 



THE APHTHA 681 

tensity. I think we have not the disease which he terms ' muguet,' 
or I do not understand his description : as far as I have been able 
to compare them, they are identical. The difference may consist in 
the modification which a hospital may give it ; if there be a differ- 
ence, I think it must be owing to this cause. When this efflores- 
cence is extensive, the child slavers very much, and is frequently 
embarrassed in its sucking ; it cries, and evidently betrays that it is 
in pain ; it is very restless and very thirsty, as it evinces by its 
frequent stirrings, and its disposition to be continued at the breast. 
The eruption in its mildest form is very white, and looks as if a 
stratum of milky coagulum were spread over the mouth. It some- 
times confines itself to the centre of the cheeks, at others to the 
lower lip, or one side of the tongue. In its severer forms the ap- 
pearance of the eruption is of a dark-brownish color or extremely 
red, owing, most probably, to minute portions of blood ; but both 
are evidently grades of the same affection, changed either by mis- 
management, constitution, or the force of the remote cause. 

" This affection is thought to be altogether of a symptomatic kind, 
or very rarely idiopathic. It is almost uniformly preceded by a 
deranged condition of the stomach and alimentary canal, and always, 
we believe, by some disturbances of the stomach itself. The brain 
always shows signs of participating in this complaint, as there is 
almost always an unusual inclination to sleep, though the child is 
frequently disturbed in its nap by some internal irritation, perhaps 
of the bowels themselves. This disposition to sleep is so well known 
to nurses that they will frequently tell you 'the child is sleeping for 
a sore-mouth.' The bowels are often teased by watery, acrid stools, 
of a greenish color ; their discharge is frequently attended with the 
eruption of much wind, and, to judge from the noise, it would be 
supposed there was a very large discharge of faeces, though, upon 
examination, it is found to be very sparing. 

" The alvine discharges are frequently very acrid, so much so, 
sometimes, as to excoriate the verge of the anus and nates very 
severely, especially when due attention is not paid to cleanliness 
or to the frequent changing of the diapers. But this never takes 
place until the disease is pretty well advanced, and has made some 
progress. It is generally pretty well spread over the mouth, and 
always shows a violent disease. The stomach is also sometimes 
much deranged ; vomiting the milk very soon after it is received 
into the stomach, in the form of a dense curd, mixed with a porra- 
ceous mucous substance. If the milk be not voided by vomiting, 



682 ORAL DISEASES AND SURGERY. 

the stomach constantly discharges, by eructations, a gas with a very 
sour smell. The child, when the disease is severe, soon becomes 
debilitated, and rapidly emaciates ; it is almost constantly harassed 
by severe colics and profuse diarrhoea; its stomach will scarcely 
retain the little it can swallow; the oesophagus sometimes be- 
comes so loaded with aphthae that it can no longer transmit the 
small quantity which is reluctantly admitted into the mouth ; and 
the child dies, either from the exhaustion consequent upon the pro- 
fuseness of the discharges from its bowels, or from inanition. 

"It is a popular belief that this aphthous efflorescence passes from 
the mouth through the whole tract of the alimentary canal to the 
very termination of the rectum ; and the excoriation at this part is 
offered as evidence of the fact. "Whether this be true or not we do 
not know, for we are not in possession of any facts from dissection 
which decide the point. TTe once examined a body which certainly 
died from aphthae, the examination of which would by no means tend 
to confirm this common belief. A child, on the tenth day after birth, 
was observed to have a number of white spots upon several different 
portions of its mouth, which rapidly spread over its whole surface. 
It had the usual premonitory and accompanying symptoms, which 
increased daily in severity, in spite of every effort to oppose them. 
It was a feeble, weakly child, of a consumptive, feeble mother. Its 
sufferings were very great, though under some control from lauda- 
num, so long as it could be taken by the mouth, or retained by in- 
jections. Coat after coat of aphthae was thrown off, and each new 
crop appeared to be more abundant, and less amenable to remedies, 
until at last, at the end of two weeks of severe suffering, the poor 
infant could not swallow a drop of the thinnest fluid. Injections of 
bark and mutton-tea, in conformity with popular opinion, were re- 
sorted to, but all in vain; the child, in a few days more, died from 
absolute starvation, or, at least, the catastrophe was certainly hurried 
by the impossibility of receiving nourishment. 

" We examined the body after death : we found the whole tract of 
the oesophagus literally blocked up with an aphthous incrustation, 
to the cardia, and there it suddenly stopped. The inner coat of the 
stomach bore some marks of inflammation, as did several portions 
of the intestines; but not a trace of aphthae could be discovered 
below the place just mentioned. This case would, therefore, create 
a doubt whether this affection besieges any other parts of the body 
than those just stated, namely, the mouth, posterior fauces, and the 
oesophagus to the cardia, since, perhaps, none could have been of 



THE APHTHjE. 683 

greater severity; but it is with us a solitary case, and should not be 
received for too much. Dr. Heberden says, ' The aphthae are sup- 
posed not only to infest the mouth and fauces, but to be continued 
down through the whole intestinal canal. In two who died of lin- 
gering fever, and whose mouths were covered with aphthae, which 
hung in rags all over it, there was not the least trace of them that 
could be found in dissection beyond the fauces. '* The excoriations 
about the anus can certainly be accounted for, without the presence 
of aphtha? to produce them ; in bad cases, the stools are always ex- 
tremely acrid, and the parts over which they constantly pass and 
spread are, at such a tender age, very delicate, and very readily 
excited to inflammation. 

" Dr. Good seems to admit, without hesitation, the transmission of 
aphthae through the intestinal canal ; for he says, without reserve, 
'The fauces become next affected, and it descends thence through 
the oesophagus into the stomach, and travels in a continuous line 
through the entire course of the intestines to the rectum, the faeces 
being often loaded with aphthous sloughs. 'f 

" We are afraid there is too much taken for granted in this account ; 
we know of no decided evidence of the fact, nor does Dr. Good name 
any authority for the statement. The case alluded to was certainly 
one of death from aphthae ; but in it the aphthous efflorescence stopped 
at the cardia. Is it probable that any child could survive this affec- 
tion did it travel the whole course of the intestinal canal? We 
think not : yet aphthae is rarely a dangerous disease in infancy. Dr. 
Good's description of this affection would certainly lead to the con- 
clusion that it is the ordinary march of the disease to pass through 
the bowels and manifest itself at the verge of the anus. This point 
is far from being settled in the minds of pathologists : even the 
French are far from having ascertained it with certainty ; it is true 
M. Billard says he has seen evidences of it in the large and small 
intestines, as well as the stomach ; but there is no mention of it 
lower than the ileum. 

" Now, this cannot be so ; since it is in violent and long-protracted 
cases alone that the anus discovers any signs of irritation from this 
cause, which would not be the case were Dr. Good's account correct. 

* Commentaries, p. 31. " It is well known, too, that in smallpox no pus- 
tules are traced beyond the pharynx and larynx, even in the most severe 
cases, when the mouth and tongue are thickly covered with the eruption." — 
Tweedie's Illustrations, p. 65. 

f Study of Medicine, vol. ii. p. 391. 



684 ORAL DISEASES AND SURGERY. 

" Dr. Good and others suppose that aphthae communicates itself by 
a specific contagion,* and give as evidence the excoriations of the 
nurse's nipples. We do not hesitate to believe there is a discharge 
from these little pustules which may be highly acrimonious to the 
denuded skin ; but we think this is perfectly innoxious to a sound 
one. For we have never seen sore nipples produced by aphthae, 
where the skin of these organs was perfectly sound. That they 
aggravate the tenderness and inflammation, when these parts are 
tender and abraded, we admit, and so would any other acrid sub- 
stance, without having recourse to the belief of a specific contagion. 
If this were the case, why do not the lips of children laboring under 
this affection betray its influence ? 

" That this , complaint is occasionally epidemic there is every 
reason to believe; and this circumstance, among some others to be 
mentioned, renders the opinion so commonly credited (of its being a 
sympathetic affection) very questionable. We have always con- 
sidered aphthae as arising from some peculiar condition of the stomach ; 
but, from some late cases and more mature reflection, we think it 
may be otherwise. Our reasons for doubt are, — 

" 1. We have recently seen this affection in two cases where the 
stomach and bowels were in the most perfect order before the erup- 
tion, but became disturbed a little during the progress of the disease. 

" 2. That this complaint has been very often removed by topical 
applications alone, where the efflorescence has been very consider- 
able, and where there was no remedy of any kind addressed to the 
stomach and bowels. f 

" 3. That we do not uniformly see this complaint where there has 
existed great disorder of both stomach and bowels, and these of a 
permanent kind. 

"4. That, however the stomach and bowels may be disturbed by 
acidity or other inconvenience, or however long these may continue, 
if the child has had this complaint, it is not renewed, though the 
individual is not exempt from a second attack, like measles or small- 
pox ; for, in certain chronic affections, they may be again visited by 
aphthae. 

u 5. That this affection is sometimes epidemic, as stated above ; 
for Dr. Good informs us that not only all the children of the same 

* M. Billard declares it not to be contagious. 

f Query. — Is, then, the unconquerable diarrhoea, sometimes present, a 
mere accident, or would it not be more easy to account for it by the presence 
of aphthae ? 



THE APHTHA. 685 

family, however cautiously separated from one another, but many of 
those of the same neighborhood, have been known, at times, to 
suffer from it simultaneously. (Yol. ii. p. 391.) 

" 6. That this disease is almost always ushered in by some cere- 
bral affection, as great drowsiness or watchfulness ; the first is by 
far the most common. 

" 1. That other portions of mucous membranes are liable to the 
same kind of eruption, without the condition of stomach or bowels 
being instrumental in its production; for we have seen it most 
plentiful within the labia pudendi, as well as on the internal face of 
the prepuce. 

" These facts have made us lately question the sympathetic origin 
of aphthae: yet we admit they are not altogether conclusive in our 
own mind ; but we thought it proper to suggest the possibility of its 
being an idiopathic disease of the mucous membrane. 

" This affection is not confined to early infancy; it shows itself in 
the more advanced periods of childhood, and from that to any period 
of human life. It is sure to attend the last stages of almost every 
long-protracted disease, especially those which may have wasting 
discharges, such as phthisis pulmonalis, dysentery, or diarrhoea; 
and when it does appear, it is almost sure to be a fatal harbinger. 

"This disease is not essentially accompanied with fever; if it 
accompany any chance affection which is attended by fever, we do 
not find it to heighten the existing one. 

"Weakly children, and especially those born before their full 
period, are more obnoxious to this complaint than the robust and 
those who have tarried to their full time in the uterus: the children 
of weakly women, and particularly those who make bad nurses 
from scarcity of milk, or from its not being of a sufficiently nutritious 
quality, are more disposed to this affection than the children of hale 
women, who have plenty of nourishment of good quality. The 
children fed much upon farinaceous substances are especially ex- 
posed to the attack of this disease, particularly when their food is 
sweetened with brown sugar or molasses." 

In the work by M. Jourdain " On the Surgical Diseases of the 
Mouth" is a chapter on aphthae, so unlike all that precedes it, as 
connected with modern pathology, that I cannot but think the book 
owes the presence of the chapter to the translator rather than to the 
author. 

"The term aphthae," says this work, "is used alike by ancients 
and moderns, but in quite a different acceptation. The former define 



686 ORAL DISEASES AND SURGERY. 

aphthae as superficial malignant ulcers, attended with heat, occurring 
especially in infants, and not confined to the mucous membrane of 
the mouth. It is at the present day universally applied to those 
whitish pustules which appear on the mucous membrane of the 
mouth, and sometimes of the adjoining parts. Inattention to this 
difference has led many to apply to the latter disease a treatment 
based upon the definition of the ancients, whereas the two are pal- 
pably different. 

" Aphthae have been regarded as ulcers ; but ulceration implies 
solution of continuity, whereas in true aphthae there is no erosion 
or decrease of substance, but, on the contrary, an increase ; desqua- 
mation of the aphthous crust leaves no trace of cicatrization. Theo- 
rists speak of white, red, and black aphthae, according to the nature 
of the generating humor ; but during a long practice I have never 
seen them of any other color than white, whitish, or, especially when 
of an unfavorable character, ash-colored. 

" They commence by small white spots, usually on the uvula, 
thence spreading, sometimes over the veil of the palate, sometimes 
over the tongue, gums, and inside of the lips and cheek. Often 
they spread still farther into the pharynx and oesophagus. Of their 
extension beyond this we cannot, of course, have the evidence of 
sight; but we have other and unequivocal symptoms, which prevent 
us from regarding as an absurdity the idea of their presence in the 
oesophagus, stomach, and smaller intestines ; as, for instance, in the 
difficulty of breathing and deglutition ; also in the appearance of the 
discharges from the stomach and bowels, so frequent in aphthous 
disease. 

" The description of aphthae is easier than their etiology. We 
maintain that they depend in all cases upon the same cause, differing, 
indeed, in degree of intensity, but never in its nature. We therefore 
differ from those who assign one cause in adults and another in in- 
fants. Nor can we agree with the many who make them to arise 
from excess of serum or of acid in the milk or nourishment given to 
the infant. The depleting, purging, and starving treatment based 
upon this hypothesis is most pernicious ; moreover, experience tells 
us that this very acidity or astringency of aliment will frequently 
cure aphthous eruptions, or prevent them from coming to maturity; 
and a serous flux, determining to the mouth, has caused the complete 
disappearance of existing aphthae. 

"What, then, is the true origin of this disease? We believe it 
to be found in the existence of a slow and imperfect crisis, and to 



THE APHTHA. 687 

arise from a sulphurous humor generated in the larger vessels, and 
determining to such parts as are, by position or structure, most im- 
pressible. Observe for a moment the circumstances and character 
of aphthae. In all fevers, in the young and in the vigorous, their 
appearance is ever preceded by a crisis more or less distinct, and, 
according to the violence of the primary disease, marked by more or 
less severe, symptoms. In one case nature struggles successfully 
with the acrimonious morbific principle, a favorable crisis occurs, 
and an aphthous eruption brings great relief to the patient; in 
another case this morbific principle is too abundant, obstinate, or 
malignant, — no crisis occurs, — no aphthae, — nature succumbs, and 
the patient dies. Again, we have aphthae through the critical transfer 
of morbid action from some more or less vital and important organ. 
In some cases the change proves salutary ; in others there is a reac- 
tion, the aphthae disappear, and if the vis vitm be not destroyed, it 
is often greatly endangered. 

" Aphthae rarely occur in a perfect and favorable crisis, but rather, 
as we have before said, in those which are slow and imperfect, such 
as are met with in a great number of diseases. Thus we find some 
aphthous eruptions of not only days', but weeks' and months' con- 
tinuance. When, for instance, necessary evacuations have been 
neglected in the onset of disease, and a cachectic plethora has super- 
vened, the cure is slow and incomplete without the occurrence of 
aphthae. Diuretics and gentle enemas aid the recovery ; blood-let- 
ting and purgatives retard it: the aphthae disappear after fulfilling 
their sanative purpose, and the patient feels perfectly relieved. Ex- 
perience, however, shows that the danger is not quite over: some 
lurking matter may take fresh increase, give rise to new aphthae, 
in default of other means of escape from the system, and greatly 
endanger life ; this may happen twice, or thrice, or oftener. 

" The causes or antecedent symptoms of aphthae may be mild, and 
recovery take place without any or with very simple treatment; or 
they may be severe and lamentable, ending in suffocation, delirium, 
or obstinate diarrhoea. This difference we find explained by the 
varying state of the humors : at one time being crude, and by con- 
sequence irritating, at another time matured or concocted, by which 
process of concoction the more hurtful principles are expelled, — a 
process aided in some inexplicable manner by the continued circu- 
lation of the animal spirits. Thus it happens that the aphthae of 
seventh-day crises are usually more unfavorable than those which 
follow crises of a later date, when the morbid matter has had time 
to undergo a thorough concoction. 



688 ORAL DISEASES AND SURGERY. 

"Although aphthae are most generally preceded by febrile mias- 
mata, they are not necessarily so. I have seen cases, both among 
adults and infants, in which they have been neither preceded nor 
attended by fever. In infants we may properly suspect impurity 
of the mother's blood. 

"Certain evacuants have been found more hurtful than beneficial 
in the treatment of aphthae. This comes from a forgetfulness of the 
excellent advice of Hippocrates, who tells us to have regard, in the 
choice of depleting agents, to the channels of evacuation which 
nature points out in any given case. Now, the vessels concerned in 
the critical discharge of an aphthous eruption are the lymphatic 
rather than the venous or arterial vessels. Therefore to the changes 
of the lymphatic fluid, rather than to those of the blood, is our atten- 
tion to be mainly directed in the management of this disease. We 
have frequent evidence of serous or lymphatic engorgement at the 
outset of aphthous eruptions : in the fever, stupor, and restlessness 
during sleep, — indicating a fullness of the head and an acrimony of 
the humors. 

"Aphthae are more common in some countries than in others, 
which explains the almost total silence of some writers respecting 
them. This depends upon difference in climate and mode of living. 
In warm countries their course is rapid, from the increased perspira- 
tory action of the skin. But in colder latitudes, where the food is 
coarser, the habit of body denser, and the humors thicker, their 
progress is slower, because the secretions of the system generally 
are more liable to obstruction. In these countries, especially, all 
discharges which tend to arrest perspiration, such as hemorrhoidal, 
intestinal, or uterine, whether occurring spontaneously or artificially 
provoked, are very unfavorable in the treatment of aphthae. On the 
contrary, a copious cutaneous or urinary secretion forms often a favor- 
able crisis. This agrees with the doctrine that aphthae are essentially 
serous, and most readily cured by a free discharge of serum or lymph. 
The cause of endemics we leave others to explain ; each country 
bears in its womb the seeds of its own diseases, and also the means 
for their cure. External agencies may cause aphthae, not, as the an- 
cients supposed, by their direct action on the mouth, but indirectly, 
through the mass of the circulating fluids. 

" The diagnosis of aphthae is easy ; not so the correct interpreta- 
tion of their premonitory symptoms. Painful deglutition, dryness 
of the mouth, a thick, husky voice, heat of the stomach, with rum- 
bling noises, disturbed, unfreshing sleep, — these often precede aph- 



THE APHTHA. 689 

thous eruptions. Urinary symptoms are not to be relied upon, though 
often useful in prognosis after the appearance of the eruption. In 
the different forms of fever, the obstinacy of the disease is often a 
precursory symptom ; when, notwithstanding the intestinal, urinary, 
and other evacuations, there still exist great depression and em- 
barrassment of the vital functions, the appearance of aphthae will 
often in a single night bring calm and relief to the patient, as ex- 
perience has abundantly testified. The physician should follow 
nature's hint, and seek to aid in the cure of the disease through the 
same channels. The above symptoms, be it understood, are by no 
means necessarily followed by aphthous eruptions. 

" We should be careful in our prognosis: where the system is not 
weakened, the pre-existing morbid matter well concocted, or the 
extent of the eruption limited to the palate, we may anticipate a 
favorable issue. But if the patient be in a reduced and weakened 
condition, the morbid matter crude, or the aphthae covering the entire 
membrane of the mouth and pharynx, the disease is much more to 
be feared. Again, suppression or derangement of the menstrual flux 
is unfavorable, from its tendency to draw the eruption from the 
place where alone it can properly mature. Profuse alvine or hemor- 
rhoidal discharges are also hurtful ; also any catarrhal attack falling 
upon the throat, causing the sudden disappearance of the aphthae. 
Aphthae occurring in diseases at the onset of which there was in- 
sufficient evacuation, are grave and dangerous. The disease may 
occur in persons of either sex, and be of tedious duration ; but when 
the appetite returns, not only is the food highly relished, but it gives, 
by its new nourishment, relief and salutary benefit." 

"The term aphthae," says Prof. Wood, in his "Practice of Medi- 
cine," vol. i. page 501, " was employed by the ancients to signify 
various inflammatory affections of the mucous membrane of the 
mouth. Willan proposed to restrict it to a peculiar vesicular eruption 
upon the membrane, but committed the error of confounding with this 
affection the thrush of early infancy. The two complaints are quite 
distinct, and should not be similarly designated. Aphthae, in com- 
pliance with very general custom, is extended to all those small 
ulcers, with whitish surface, which so frequently appear in the 
mouth, whatever may be their origin. The most frequent source 
of aphthae is probably the vesicular eruption occasionally present in 
erythema. The vesicle is small, oval, or roundish, white or pearl- 
colored, and consists of a transparent serous fluid under the elevated 
epithelium. In a few days the epithelium breaks, the serum escapes, 

44 



690 ORAL DISEASES AND SURGERY. 

and a small ulcer forms, more or less painful, with a whitish bottom, 
and usually a red circle of inflammation around it. The vesicles are 
sometimes distinct and scattered, sometimes numerous and confluent. 
The distinct variety, though painful, is a light affection, continuing 
in general only a few days or a week, and is usually confined to the 
mouth. It produces little or no constitutional disorder, though it 
may be associated with fever and gastric irritation as an effect. It 
attacks equally children and adults, but is said to be very common 
in early infancy. In adults it is frequently occasioned by the irrita- 
tion of decayed teeth. The confluent variety is much more severe 
and obstinate. This frequently extends into the fauces and pharynx, 
and is said to reach even the intestinal canal, though it may be 
doubted whether the affection of the stomach and bowels is identical 
with that of the mouth." 

The French fail in distinguishing, with Prof. Wood, the difference 
between the pultaceous inflammation of thrush, or muguet, and the 
aphthae, calling muguet the " aphthes des enfans." They recognize 
also that there are variations in the expressions of the condition, 
making a distinction between the muguet benin ou discret, and the 
confluent, muguet malin ou confluent. 

In Clymer's Aitken's " Science and Practice of Medicine," the 
subject is thus alluded to: "Follicular inflammation of the mouth, 
follicular stomatitis, aphthous stomatitis, or aphthae of the mouth, is 
a disease which usually commences as a simple stomatitis ; but 
very soon small, round, transparent, grayish or white vesicles appear, 
and at the base of each is an elevated marginal ring, which is pale 
and firm. Fluid soon escapes from the ruptured vesicle ; an ulcer 
forms, which spreads, bounded by a red circle and an elevated 
border. In some forms of the affection microscopical parasitic 
plants appear." 

Treatment. — If we are content to view aphthae simply as a fun- 
gous sore, originating from and maintained by the presence of a 
parasite, — the oidium albicans, — we would find a most admirable 
application in carbolic acid, admitting that the parasite had an ex- 
ternal relation only; if, however, these spores come from within 
and are exudational, such local treatment would be of very temporary 
service. 

Viewing the fungus simply as an accidental parasite external in 
its relations, our attention is directed primarily to the necessity for 
cleanliness, and the avoidance of all positions, locations, and circum- 
stances favoring the development of fungi: carbolic acid, acid nitrate 



>TRE APHTHA. 691 

of mercury, sulphuric acid, nitrate of silver, or chloride of zinc, will 
be found destructive to the parasite, and, of necessity, if the circum- 
stances are changed, equal to the production of a permanent change 
in the appearance of the part ; that is to say, the application is equal 
to the removal of the envelope or cover of the disease, but, except by 
a happy accident, will not beneficially affect the underlying condition, 
or the disease proper. 

In the treatment of aphthae, the practitioner finds himself com- 
pelled, at the very outstart, to consider the constitutional associa- 
tions. Occurring in connection with acute diseases, it is generally 
the case that the local expression is found to disappear with the 
condition exciting it. Thus, in febrile attacks attended with stoma- 
titis, we direct our remedies to the causes inducing such attacks ; 
as the functions become harmonized and regulated, the expressions 
of the irregularity disappear. 

Aphthae, whatever its form, appearing in connection with the 
dyscrasic diseases, gives to the practitioner the greatest anxiety and 
trouble. In our anticipations of what we are to do, we are not to 
forget that the task before us is the removal, or, at least, the marked 
amelioration, of the constitutional disease. If this should be syphi- 
litic, tubercular, or cancerous, the magnitude of the task is evident : 
hence it is that patients are allowed so frequently and so unneces- 
sarily to find themselves subjected to a series of disappointments. 

Acute aphthae, as manifested in cancrum oris, gangraena oris, and 
follicular inflammation, demands not unfrequently the most attentive 
local treatment. This treatment has, however, nothing particularly 
special in it, and, without doubt, must be appreciated from the 
general expressions of the subject. Alteratives and soothing appli- 
cations are such as would naturally commend themselves. Sulphate 
of copper, in proportions varying from five to thirty grains to the 
ounce of water, is an excellent application. Iron and quinine in 
combination are used to great advantage, — twenty-five grains of the 
latter to one drachm of the muriated tincture. A powder made by 
combining equal parts of red bark, chalk, and tannic acid is fre- 
quently found very serviceable. Solutions of alum, and the tinc- 
tures of capsicum and myrrh, are useful in their places ; also borax, 
oxalate of cerium, powdered chlorate of potash, sulphate of iron, etc. 
Hydrochloric acid, applied by means of a feather or small brush, 
causes less pain than might be supposed, and is thought by many 
to be the very best local application that may be employed. 

Where the parts seem angry and irritable, or phagedenic, com- 



692 ORAL DISEASES AND SURGERY. 

bined with these applications are to be employed the more soothing 
means: starch, gum, and slippery-elm water being found in such 
directions very serviceable. Tincture of hamamelis, much diluted, 
is a good preparation. Another is the phenate of soda. It is to be 
understood that while the principles which govern the treatment of 
the aphthae are common to the species, the applications must vary 
to meet varying local indications. The ordinary white sores, for 
example, need little more in the way of such direct treatment than 
the continued application to them of some of the agents mentioned: 
which one would be best, or, indeed, what would be best, we could 
not well say, unless considering a particular case. The local treat- 
ment is not, however, in any of these cases urgent, and it is the 
general experience that we find ourselves trying first one thing and 
then another ; indeed, it is unfortunately too common that we are 
soon brought to the conviction that any local application is un- 
reliable, — not that we cannot cause a sore to disappear, but that 
to-day, to-morrow, or next week, another comes to take its place. 
Canker sores seem periodic in some persons ; they come without 
perceptible cause other than what seems a persistent constitu- 
tional condition, defy all treatment, and finally disappear of their 
own accord. 

Of the special conditions, thrush demands that the bowels should 
be kept free from costiveness, — oil, the saline cathartics, or aloes 
being employed as indicated. Where fever attends the local mani- 
festation, it is well to prescribe the neutral mixture made by fully 
saturating lemon-juice with the carbonate of potassa ; or, if more 
agreeable to the patient, the ordinary lemonade may be used. In 
diarrhoea, which is so frequent an attendant on thrush, some such 
combination as the following may be used : 

R. — Hydrargyri cum creta, gr. ij ; 

Pulveris opii, 

Pulveris ipecacuanha?, aa gr. j ; 

Magnesia? carbonatis, gr. xij. M. 
Ft. chart. No. xii. 

Of these powders, the infant may take one, mixed in molasses or 
other vehicle, every two hours, until the discharge is checked, or 
until the twelve are taken. In diarrhoea with green discharges it 
may be sufficient to use the magnesia alone ; or lime-water, which is 
more convenient of exhibition, may suffice for the correction of the 



THE APHTHjE. 693 

acidity: this latter can be rendered palatable by adding to it some 
of the aromatic waters. A combination, for the knowledge of which 
I am indebted to my eminent colleague Prof. Penrose, and which it 
would seem could scarcely be replaced by a better, is as follows : 

R. — Bismuthi subnitratis, 

Myristicae pulveris, aa 5U ; 
Cretae preparatas, 9ij ; 
Syrupi zingiberis, §iss. M.* 
Dose, from twenty-five drops to a teaspoonful, according to age, 
repeated every two hours. 

In cases associated with much intestinal disturbance, it will in 
most instances be found satisfactory practice to combine laudanum 
or paregoric with olive- or castor-oil, administering in such doses as 
accord with the age of the patient. A child one year of age may 
take three drops of laudanum or twenty of paregoric, combined with 
a teaspoonful of the oil ; for an adult a dose would be twenty-five or 
thirty drops of laudanum to a tablespoonful of the oil. It is also 
found useful to drink freely of the demulcent waters, marshmallow 
and gum arabic being among the best of these. In debility, — and 
this is by far the most frequent of the conditions, — combinations of 
iron and bark, conjoined with the most nutritious articles of diet, 
will be found indicated : ferrated elixir of cinchona is a pleasant and 
very reliable preparation, and is freely taken by children. The dose 
for an adult is one teaspoonful, repeated three or four times a day; 
to an infant a year old, ten drops may be given. 

Concerning the diet, if the patient is beyond the age of infancy, 
it will be found that the richest food is most advantageously re- 
ceived ; juicy beef, oysters, malt liquor, wine, etc., being freely 
allowed. In the infant, the character of the milk of the mother is to 
be examined : in many cases it will be found needful to furnish a 
different nurse, or, otherwise, wean the child. Many cases of per- 
sistent thrush in the infant have quickly disappeared after a change 
of nurses. 

Gangraena oris, the most degenerative and destructive of the 
aphthae, requires the most persistent vigor in the treatment, both as 

* The author is assured that his readers will recognize the obligation he 
places them under in directing attention to this palatable combination. As 
a medicine for the ordinary diarrhoea of summer, both in the infant and adult, 
it will seldom be found to disappoint in affording the desired cure. 



694 ORAL DISEASES AND SURGERY. 

regards systemic and local conditions. Sulphate of quinia and the 
muriated tincture of iron are, in the first direction, most to be relied 
on. This condition occurs most frequently between the periods of 
first and second dentition, and is, without doubt, more common to 
the miasmatic than to other regions, excepting always the location 
of ill-kept and ill-ventilated charities. Gangraena oris may have a 
local excitant, but it is never without a constitutional predisposition. 
It may commence as a simple sore, gradually degenerating, or, as in 
carbuncle, destruction may reside in the primary impression. A 
common form of sloughing stomatitis is its appearance as a whitish 
or ash-colored eschar situated upon the gums, lips, or cheeks. This 
eschar quickly falls out, being followed by degeneration of the asso- 
ciate parts ; the breath becomes offensive, the saliva flows as in 
ptyalism, while, to add to the discomfort, the ulcer pours out an 
acrid, corrosive fluid, which not only excoriates the mouth, but 
seems to provoke the extension of the mortification. If not checked, 
the ulceration extends to the bone, quickly involving it in the gen- 
eral destruction, and bringing on the condition of necrosis, — necrosis 
infantilis, as the disease is, unfortunately, so frequently compelled 
to be namedl 

The treatment of gangrsena oris is precisely that of a carbuncle. 
We endeavor to circumscribe the action by sloughing out the af- 
fected part with the aid of caustic ; this accomplished, we stimulate 
the general system, correct, where possible, all functional disturb- 
ances, and use for the relief of the local sore such soothing means 
as seem indicated. 



CHAPTER XXXV. 

RANULA. 

The subject of ranula is one easily comprehended. A ranula is 
the analogue of the sebaceous tumor, being simply a tumor of re- 
tention, a collection, the result of the closure of a tube of outlet. 
The tumor thus designated is found principally beneath the tongue ; 
it is a swelling varying in size or in expression according to the cir- 
cumstances of its existence, at times being observed when not larger 
than a pea, at others so great in bulk as to throw the tongue back 
into the fauces. Ranulae will sometimes be met with which fill the 
whole oral cavity; such dimensions, however, are uncommon. 

Recalling the anatomy of the salivary glands, we remember that 
the submaxillary, situated beneath the jaw, has the outlet for its 
secretions in a tube opening at the side of the frsenum linguae, — the 
duct of Wharton, as it is called. The lingual gland empties itself 
on the same line. The parotid, by its tube, the duct of Steno, opens 
upon the mucous face of the cheek opposite the superior second molar 
tooth. While patulous, these tubes convey into the mouth the secre- 
tions of their respective glands, and thus the saliva, passing to its 
recremental purpose, is disposed of. 

If we were to tie or otherwise obstruct one of these tubes, it 
would be natural to expect that the secretion accumulating back of 
the ligature would expand and bulge out the duct into the form of a 
tumor. This is really the very simple history of the formation of a 
ranula. 

Ranula, thus provoked and thus formed, varies as much in appear- 
ance and character as in size. In one case it will look and feel 
almost precisely like the belly of a frog, the enveloping cyst being 
thin and attenuated. In other instances the walls are thick. The 
contents present varying characteristics, being watery, or semi-solid, 
or solid, even to the hardness of stone, as illustrated in the very in- 
structive case cited in the chapter on Salivary Calculus. Commonly 
the contents consist of a yellow, albuminous-like substance, which, 
for its evacuation, requires pressure upon the tumor after an in- 
cision has been made. 

(695) 



696 ORAL DISEASES AND SURGERY. 

A ranula, the contents of which are watery, implies, as a rule, 
that the disease has been of short existence, the fluid being simply 
the secretioD from the gland unchanged in character. In the ranula 
of semi-solid consistence an explanation is found in the partial 
absorption of the more fluid portion, leaving an inspissated mass. In 
the solid ranula the encystment is the common salivary calculus, — 
being precisely the same as is found upon the sides of the teeth, 
excepting in the absence of the common detritus of the mouth. Such 
a ranula will be found to be of long standing: absorption of the watery 
portion has gone on until what remains is the limy portion of the 
secretion. 

A thin cyst implies a rapidly-formed tumor unattended by vascular 
excitement, the envelope being a simple attenuation of the walls of 
the duct and overlying parts. This form of ranula very frequently 
ruptures, and thus effects a self-cure. Cysts, thickened and hard, 
imply tumors of slower growth and the association of vascular 
changes resulting in the effusion within the cyst-wall, and the 
organization of a greater or less amount of lymph. Cysts thus 
thickened may compose the principal bulk of ranulae, the cavities 
being very small in comparison. 

A ranula gives trouble from its bulk and location alone, seldom or 
never degenerating. It does not seem true, either, that harm results 
to digestion from the loss of the secretion, such loss, indeed, being 
more apparent than real, the associate glands performing excess of 
work. A ranula attaining great size would necessarily intrude upon 
all the surrounding parts, thereby provoking secondary lesions which 
might very well prove of more serious character and consequence 
than the original disease : thus, cases are on record where the teeth 
have been forced from their sockets, where large ulcers have been 
formed against the inner face of the lower jaw, where necrosis 
of extensive character has been provoked, etc. 

Treatment. — This, in principle, consists simply in opening the 
tumor, evacuating its contents, and so conducting the cure of the 
wound that it shall not entirely close, securing and preserving in 
this way an orifice of exit for the secretion. 

In the rana, or frog-belly tumor (for here there is ranula of both 
sides), it is found sufficient to catch up with the tenaculum or forceps 
a portion of the sac, and with the scissors or bistoury cut it off: the 
edges are then to be cauterized, and the case left to nature. 

In the thickened cysts such an operation as just suggested might 
not be easy to accomplish. In such a case take a strand of ligature 



RANULA. 697 

wire (silver is to be preferred), double it upon itself half a dozen 
times, to the extent of the supposed thickness of the sac of the 
tumor to be operated upon. Take next the continuation of the 
length of the wire, and closely, yet spirally, bind with it the thick- 
ness just secured by the half-dozen reflections. Next take a curved 
needle, and thread the wire to it. Now pass it through the tumor, 
entering at the centre. When the thickened part of the wire — 
which is to be bulbed by a perforated shot compressed on its ex- 
tremity — is brought in contact with the cyst, it is to be let in by an 
incision just large enough to allow the passage; pull it now in, until 
checked by the shot ; fix the needle-end so as to retain the thickened 
end in place, and the operative part of the proceeding is completed. 

A second mode, founded on the same principle of drainage, con- 
sists in taking a delicate rubber tube, and, after cutting through its 
walls a number of outlets, passing it through the tumor. To retain 
it in place, the extremities are tied together, having an opening 
made between the ligature and the tumor. 

If, when making the little section in the tumor for the passage of 
the wire or tube, the contents should not at once escape, they are 
to be pressed or syringed out. If the parts seem particularly indo- 
lent, there is no objection to the introduction of a stimulating injec- 
tion. The presence of the drain will, however, in ordinary cases 
prove sufficiently provocative of the desired action. Iodine in tinc- 
ture may be used externally over the face of the tumor. 

In a ranula holding a calculus within the cyst nothing is to be 
done without using the knife, except, indeed, in certain occasional 
instances where the orifice of the duct has become patulous and the 
stone can be seen or felt. In these cases the operator may succeed 
in drilling or breaking it in pieces, and thus securing its removal. 
It is much easier, however, even here, to incise down to the stone, 
and thus take it away. The case alluded to as mentioned in the 
chapter on Salivary Calculus is as good a study as could be given 
in the direction. 

All cysts or tumors found beneath the tongue are not, however, 
to be esteemed as being of the character just described. Inflamma- 
tion of the sublingual gland is not unfrequently met with, and the 
tumefaction is, at times, so considerable as to very closely simulate 
ranula. Cysts within the substance of the glands, not salivary in 
character, are other of the conditions encountered, and these more 
closely simulate the ordinary ranula than the first, particularly when 
the cyst is simple. Papillary indurations are sometimes met with 
in the same situation. 



698 ORAL DISEASES AND SURGERY. 

Lipoma simulating ranula is found occasionally referred to.* 
Writers, prominent among whom is M. Marrant Baker, are found, 
who incline to doubt the common relation of the condition with the 

* " Lipoma simulating Kanula. — Mr. F. Churchill exhibited a specimen 
of lipoma simulating ranula. He said this tumor was removed from under 
the tongue of an old man, eighty-six years of age. The specimen is unique, 
so far as the Society is concerned. I have been unable to find in the Trans- 
actions any records of a lipomatous tumor removed from this situation, and 
there is no such tumor in the Museum of the College of Surgeons. Mr. Liston 
refers to the removal of fatty tumors under the tongue in his work on Practical 
Surgery. Mr. Pollock removed a fatty tumor from below the jaw of a lady 
forty years of age, enveloping the mylo-hyoid muscle ; but in this case the in- 
trinsic muscles of the tongue do not appear to have been encroached upon by 
the tumor. In several cases, hardened, putty-like masses have been removed 
from a ranular cyst, as also phosphatic concretions. During the last session of 
the Society, Mr. Warren Tay exhibited four or five butter-like masses, which 
he had removed from a ranular cyst, but ' under the microscope no definite 
structure could be detected in them. Entangled in the substance composing 
the masses were some cells and portions of cells looking like debris of epithe- 
lium.' Dr. Meymott Tidy, after a careful chemical analysis, 'was disposed 
to regard the bulk of the deposit as adipose.' The history of the case was as 
follows: H. T., aged eighty-six, was admitted to the Westminster General 
Dispensary, under the care of my colleague, Dr. Waite, who treated him for 
eczema rubrum of the leg. After consultation with Dr. Waite as to the na- 
ture of the tumor beneath the tongue, supposing it to be a ranula, I suggested 
that it should be removed in the usual way. He stated that on several occa- 
sions fluid had issued from the tumor, after which it was distinctly smaller. 
The incisive teeth in the lower jaw were intact, and situated just behind these 
was a movable (apparently pedunculated) tumor, about the size of a walnut, 
covered by the smooth, glistening mucous membrane of the floor of the mouth. 
The tumor was also, in part, covered by the sublingual gland ; it was soft and 
yielding, and I was under the impression that I could detect fluctuation. 
The distended mucous membrane was being chafed by contact with the sharp 
edge of the teeth during mastication. The old man had noticed the swelling 
for twenty-two years. It had gradually increased up to the present time. 
During the past twelve months, however, it had given him pain, in conse- 
quence of chafing against the teeth ; he much feared that it was a cancer. 
From its size it had also interfered with mastication, and acted as a serious 
impediment to his speech. Having removed a portion of the anterior wall 
of the tumor, I proceeded to turn out the contents, but found, underlying the 
mucous membrane, a bright, glistening mass, resembling a cyst-wall ; this 
was seized with a pair of clutch-forceps and drawn forward, a small portion 
of it being removed, but still no fluid escaped. I proceeded then to separate 
the adhesions to the mucous membrane with the spoon-end of a director, but 
the deep connections were too firm to separate in this way ; the finger also 
failed to enucleate the mass. The tumor was forcibly drawn forward, and 



RANULA. 



699 



Fig. 240. 



salivary ducts, but upon such premises, as must appear to any one 
who shall see much of the condition, that the arguments advanced 
carry no weight : the true ranulse arise from salivary lesions influ- 
encing the relations of the discharge : tumors of kindred position 
may have the signification of muciparous cysts, or may be expressive 
of a systemic vice ; because a tumor is beneath the tongue it is not 
necessarily, a ranula. 

Ranulae are found superficially seated, or deep, according to the 
part affected and the location of the lesion : 
thus, ranulae associated with the tubal outlets 
of the sublingual gland are always entirely 
superficial, because the part affected is cov- 
ered only by the mucous membrane. Obstruc- 
tion of the duct of Wharton at its orifice 
yields also a superficial tumor, lying as it 
does between the mucous membrane and 
the mylo-hyoid muscle ; occurring, however, 
beneath this muscle, the tumor resulting is 
deep-seated. 

Ranulas are of temporary or permanent 
signification : thus, where only a limited ob- 
struction exists, a tumor may form suddenly 
during the excess of secretion at periods of 
mastication, to drain gradually away as the 
superexcitation passes off. Or cases are met 
with where, as the result of accidental inflam- 
matory conditions, the outlets become obstructed from neighboring 
exudates, the tumor disappearing as the exudates are absorbed. 

The existence of true ranula does not necessarily imply that the 
tube affected is absolutely closed: a ranula may exist where obser- 




Superficial Ranula, showing 
seton introduced.* 



these deep attachments cautiously divided with the knife. In this way the 
tumor, which was lobulated, and enveloping (probably) the genio-hyoglossi 
muscles, was removed. Exploring the cavity afterwards, I could feel the 
sharp borders of the vertical muscles, and I was satisfied that the growth had 
been entirely removed. There was very little hemorrhage after the operation, 
and the cavity had completely closed in the course of a week." — Proceedings 
of the Pathological Society. 

* This is but a single expression of the superficial ranulae. One treated this 
very day of writing by the author — being a double tumor — presented the ap- 
pearance of the whole floor, of the mouth being raised on a level with the 
teeth. 



700 



ORAL DISEASES AND SURGERY. 



vation discovers the canal patulous and the secretion discharging ; 
here an explanation is found in well-known similar stricture as met 
with in the relation of the bladder and its urethral canal, urine con- 
stantly dribbling from the meatus, yet the patient suffering from 
retention; or, again, a probe may be passed with all ease into the 
orifice of a canal, yet a true tumor of retention exist, — here, as 
referred to, a stricture being deep-seated. 

Cases of hygrometric or bursal tumors are to be met with occa- 
sionally upon the neck, which may or may not be ranular. Xo more 
instructive case in such direction has ever fallen under my own 
observation than that described in the chapter on Salivary Fistula. 
A tumor precisely similar in appearance to this particular one, but 
situated beneath the right submaxillary gland, was, at a late clinic 
of the University Hospital, dissected by my colleague Prof. Agnew 
from the neck of an infant ; but here no association with the gland 
was discoverable : also, at the same clinic, a tumor of similar loca- 
tion and appearance from the neck of an adult, with similar absence 
of discoverable relation. Such tumors have the signification of 



Fig. 241. 




engorged and enlarged bursas, or at least are. to be so treated, and are 
the analogue to what is so familiar as the " housemaid's knee." 



RANULA. 701 

The salivary glands themselves are occasionally the seat of in- 
flammatory swellings, which are quite as apt to become indolent as 
to resolve. I have within my own observation several of these cases, 
and sometimes have been six months in reducing such an indura- 
tion. The submaxillary, however, seems to be the gland most dis- 
posed to take on such conditions, and the tumefaction thus produced 
is without rather than within the mouth, although it not unfrequently 
happens that it is first observed by the patient as a hard body on the 
inner side of the jaw. 

Another form of. tumor which may here be alluded to is found 
in the submaxillary triangle. 

In dissecting down to the submaxillary gland, there will be ex- 
posed, when the body is uncovered by removing the superficial leaf 
of the triangular fascia, two lymphatic glands. These glands are 
very apt to indurate, forming sometimes a tumor of considerable 
size. I have met with them as large as a walnut. It is most com- 
mon to mistake such indurations for hypertrophy of the submaxil- 
lary itself. Two diagnostic signs distinguish the first : they are not 
triangular, and they are not so solidly fixed as when the chief gland 
is the seat of the enlargement. 

A case of glandular tumor, very suggestive as a study, is recorded 
in Bell's " Principles of Surgery." The attention of the reader is 
directed to it : 

The case was that of " a young woman of Berwick, whose native 
peculiarity of accent had received a singular aggravation by such an 
uncouth obliquity and imperfect motion of the tongue as conveyed 
the notion of her attempting to chew and turn each vocable with her 
tongue before she proceeded to swallow it, in place of uttering it. 

" This was produced by a tumor of very great size, and of an 
appearance so peculiar as plainly to denote its character. It con- 
sisted in a vast collection of matter in the sublingual gland ; and as 
that gland is covered by the whole thickness of the tongue within, 
and by the mylo-hyoidei muscles without, and bounded by the line 
of the jaw-bone, it had the following singularities of character. It 
could not be distinguished as a tumor, but had rather the appear- 
ance of a general swelling of the lower part of the face, jaw, and 
neck, such as often accompanies severe toothache or mumps. Upon 
laying the hand upon the outside of the neck, below the lower jaw- 
bone, the whole hand was filled with a swelling, apparently solid, 
but so little convex or circumscribed as to resemble in no degree the 
tumor of any particular gland, and yet so limited and so firm as not 



702 ORAL DISEASES AND SURGERY. 

at all to resemble the general tumefaction proceeding from toothache. 
Upon introducing the finger into the mouth, you found the tongue 
raised, turned edge uppermost, and pressed entirely toward the left 
side of the mouth, the external tumor being upon the right side. 
Upon pressing the fingers very firmly down by the side of the 
tongue, and reaching from without, you could sensibly perceive not 
so properly a fluctuation as an elasticity, which implied the presence 
of a fluid ; the tumor seemed elastic like a football, but with a degree 
of tension which made it seem almost solid. It was by comparing 
a variety of circumstances, especially the original place and slow 
growth of the tumor, that I confidently referred it to the sublingual 
gland. In this I had the advantage of the surgeon under whose 
particular care she was ; but I did him the justice to send her back 
to him, again and again, expressing my opinion and my wish at the 
same time that he should do whatever he might suppose right. By 
good fortune, she called upon me the day she was to return home, 
nothing being as yet done to the tumor, but supplied with abundance 
of blisters and plasters to apply at a fit opportunity to her throat. I 
felt now that professional ceremonies should give way to essential 
charities. I placed her in a chair, and almost without her conscious- 
ness—at least before she was aware — I struck a fine bleeding-lancet 
deep into the tumor by the side of the frsenum of the tongue, when, 
from the firm compression of the surrounding parts, the matter, 
though too gross to pass freely through such an opening, was 
spewed out from the orifice, in a manner expressly resembling that 
in which yellow paint is squeezed out from the bladder upon a 
painter's pallet. It was of a deep saffron color, thicker than mustard, 
mixed like gruel with seed-like particles, and exceedingly fetid. I 
knew that the tumor was not emptied, though the outward swelling 
was almost gone ; but I also knew that though I should not enlarge 
the opening, the second secretion from the surface of the sac, which 
is in all cases thin, would dilute and wash out whatever viscid 
matter remained ; and when she saw how suddenly my prognostic 
was fulfilled, she expressed a perfect confidence in whatever I pre- 
dicted, and a perfect willingness to submit cheerfully to whatever I 
proposed to do. Next day I introduced the point of a probe-pointed 
bistoury into the orifice made by the lancet ; and, knowing that the 
lingual artery lies on a lower level, imbedded among the muscles, 
and running along the lower surface of the tumor, while I had over 
the point and blade of my bistoury nothing but the inside membrane 
of the mouth, much thickened, I ran it fearlessly and at one stroke, 



RANULA. 703 

as the less painful way, along the whole length of the tumor, when 
the thickest of the yellow mucus flowed freely, or was raked out with 
the points of the fingers and the handle of the bistoury; and the 
tongue, descended now to its natural level, was in a capacity once 
more of delivering the peculiar dialect of her native city in all its 
purity. 

" So tense and apparently solid was this tumor, in consequence of 
the compression by so many surrounding muscles, that her surgeon 
mistook it for a solid and strumous swelling. I reckoned that in 
this, as in all cases of sacculated tumor, the second secretion, which 
was thinner, would wash out the thicker mucus, and I was not de- 
ceived ; but she left me too early for me to witness the obliteration 
of the sac. 

"I find it, in all such cases, a matter of some importance, es- 
pecially in a girl, to anticipate the outward suppuration of any sac- 
culated tumor, by puncturing it, though to a great depth within the 
mouth and under the tongue, and equally necessary to be at pains 
in preserving the opening and obliterating the sac : a slight miscon- 
duct in this respect occasions much distress to the patient and much 
superfluous labor to the surgeon." 

Illustrations. — In his own practice the author has treated quite 
his share of cases in this direction, having had as many as three at 
a single clinic. True uncomplicated ranula he has almost always 
been able to cure, without trouble or difficulty, by the use of the 
drainage seton. Fig. 240 exhibits such a seton applied. As studies, 
however, it may not be amiss to introduce a few illustrative ex- 
amples; and, as in the practice of others he finds all that seems 
necessary, he saves himself the trouble of writing out examples of 
his own by selecting from other sources. 

" Ranula. — Operation by Dr. Hamilton. P. R. Cortelyou, House 
Surgeon. 

"Dec. 13, 1867. K., of N., aged sixteen years, private patient, 
admitted to Bellevue under Dr. Hamilton's care. 

" Soon after birth his father noticed a swelling under his chin, 
near the median line, which has continued to increase ever since. 
Now the size of a large orange, nearly in the centre, but inclining a 
little to the right side. It is not painful or tender ; its surface is 
smooth and elastic. On exploration it was found to contain a thin 
yellowish fluid. 

" Examining within the mouth, it was found to have lifted the 
tongue considerably; but its walls did not present the translucent 



704 ORAL DISEASES AND SURGERY. 

appearance sometimes seen in ranula, nor could it be decided posi- 
tively whether the orifices of the ducts on the right side were still 
open. It became a question what was the source of this enlarge- 
ment or tumor. 

" The term ' ranula' has been applied by some surgeons to obstruc- 
tions of the sublingual ducts, by others to obstructions of the sub- 
maxillary ducts, and by most surgeons to obstructions of either the 
one or the other indifferently. Certain writers, also, have extended 
the term to all encysted tumors in this region, whether occurring in 
the areolar tissue or in muciparous glands, which present a common 
external appearance like the throat of a frog. 

" It was not very clear from which of these several sources this 
tumor had originated. It was decided, therefore, to proceed as if it 
were an obstructed duct. Accordingly, Dr. Hamilton made a small 
incision into the tumor beside the tongue, on the right side, avoiding 
carefully the ranine artery. This opening was at once enlarged by 
introducing a pair of bullet forceps and expanding them, so as to 
tear the wound larger. The sac was emptied, and a piece of lami- 
naria digitata introduced. On the third day considerable inflamma- 
tion existed, extending to the root of the tongue and side of the 
face. There had been also, up to this time, a constant but slight 
hemorrhage. Both the swelling and bleeding abated from this time. 
The contents of the sac were examined under the microscope, but 
not with sufficient care to determine their character. 

" Feb. 1, 1868, nearly two months after the operation, the father 
reports that the sac has almost disappeared. A little pus continues 
to discharge, and there is no tenderness or swelling. The laminaria 
is taken out daily, and replaced with ease. It is probable that the 
complete cure will not take place under several months. 

" Dr. Hamilton mentioned that a ranula was said to form occa- 
sionally in a bursa outside of the genio-hyoid muscle; but he had 
searched for this bursa and could not find it." 

" Swelling of Submaxillary Gland from Inflammatory Obstruc- 
tion of its Duct. — Charles D. Hoyt, of Middlesex, Yates county, 
called upon Dr. Hamilton, December 29, 1846, with a moderate en- 
largement of the right submaxillary gland, it being apparently, as 
felt beneath the jaw, of the size of a large Lima bean. He stated 
that this enlargement occurred about one week before, while eating 
his breakfast, and that in five minutes it attained the size of a 
1 walnut with its bark on,' and that it prevented his opening his 



RANULA. 705 

mouth freely. After leaving the table he rubbed it for some time, 
and in half an hour it was reduced to its present size. 

"From that time the same enlargement occurred every time he 
ate, and without any reference to what he ate. It enlarged most, 
however, while eating his first meal in the morning. By rubbing 
alone could it be reduced. Chewing tobacco seemed rather to 
diminish than to increase its size. It was not tender, nor red, but 
when enlarged to its utmost it caused a severe pain, which extended 
to his ear. 

" Tincture of iodine externally was first employed by Dr. H. ; 
but, no result being obtained, he directed him to take a full dose of 
Epsom salts. This had the desired effect. The enlargement dis- 
appeared very quickly, and did not return." 

" Obstruction of both Submaxillary Ducts. — December IT, 184T, 
John C. Lyons, aged twenty, Benton Centre, Yates county, con- 
sulted Dr. H. He stated that in the latter part of July, while 
harvesting, the weather being very warm, he discovered in the 
morning a soreness under his tongue upon the left side, and before 
night he found there was a tumor at this point. It was oblong and 
only about half an inch in length. His physician, Dr. Wolcott, 
opened it the following day, and it discharged a glairy matter. 
Since then it had been opened four times ; but, a few days before 
calling on Dr. H., he discovered that there was a swelling on the 
opposite side, externally, in the region of the submaxillary gland. 
When seen by Dr. H. the gland was of the size of a pullet's egg, 
oblong, not painful or tender. It was increasing in size, but he 
noticed that it was larger in cold and damp weather. His health 
was good. He was advised to submit to a low diet, take physic, and 
apply externally the tincture of iodine. He was never seen again, 
and the result is not known. During the winter of 184T and '48 
two similar cases of enlargement of the submaxillary gland were 
presented in Dr. Hamilton's Surgical Clinic, at the Buffalo Medical 
College, one of which had resulted in an external salivary fistula. 

" In a recent report of one of Professor Jarjavay's clinics, copied 
into the number of the Gazette des Eopitaux of November 23, 
1861, similar enlargements of the submaxillary gland are mentioned 
as occurring in connection with obstructions of Wharton's duct ; 
but he restricts the application of the term ranula to obstruction of 
some one of the twenty-eight or thirty excretory ducts of the sub- 
lingual gland." 

Ranula. — In one of a series of interesting papers on "Anatomy 

45 



706 ORAL DISEASES AND SURGERY. 

in its Relations with Medicine and Surgery," Professor D. Hayes 
Agnew makes the following remarks on this subject : "A tumor is 
met with beneath the end of the tongue, rising from the floor of the 
mouth, to which the name ranula has been applied. It involves 
the ducts of the sublingual glands, the excretory orifices of which 
here open. These become obstructed by some substance, either 
mechanical or inflammatory, the secretion accumulates behind, dis- 
tending them finally into a semi-transparent tumor. Sometimes 
they are found to be firm and resisting in the texture. In such 
cases the distention has provoked an inflammatory exudation and 
its organization into fibrous tissue. The transparency will depend 
upon the attenuation of the mucous membrane. The same morbid 
condition may be present in a very limited degree, confined even to 
a single duct, so as to resemble a little vesicle. The cure of such 
can rarely be accomplished by puncture and evacuation of the con- 
tents: the wound you make will soon heal, and, as the duct or ducts 
are not restored to a previous condition, the swelling will be repro- 
duced. No treatment short of that which contemplates the destruc- 
tion of the glandular tissue will prove effectual. This is best attained 
either by injection or excision; the latter I think the preferable, 
which is readily done by including the mass within two elliptical 
incisions, and then allowing the wound to heal by granulation or 
stitching the edges together with the finest silver wire. If it be a 
small cyst, after clipping it away, the point of a stick of caustic may 
be carried into the wound for a moment or so. 

"Another tumor is found in this same locality, and which is pro- 
duced by a salivary calculus becoming arrested near the outlet of 
the submaxillary duct; and, last, another variety of tumor, which I 
am disposed to believe is rare, and being connected with the under 
surface of the top of the tongue, rather than the floor of the mouth, 
must be referred to the cluster of glands there situated. The sides 
of the tongue may be bound down by cicatricial tissue, so as to inter- 
fere with its proper functional movements. Should a nerve-filament 
happen to be included, it may give rise to a very painful condition. 
This is best remedied by incisions or exsection of the diseased struc- 
ture." 

Lately, at the Imperial Society of Surgeons there was exhibited 
by M. Paulet two salivary calculi found by him in Wharton's duct. 
In connection with the presentation was reported the unique fact — 
for such it was thought to be — that the submaxillary glands of both 
sides were found stuffed with calculi. M. Pana, however, presented 



RANULA. 707 

at the same meeting a single calculus taken by excision from this 
gland.* 

Ranula treated by Mechanical Pressure. — "Nearly seven years 
ago," says Dr. Wm. Macdonald, " J. F., aged twenty-two years, and 

residing in M Street, in this city, consulted me in consequence 

of being much distressed with a ranula, or a large tumor under her 
tongue, arising from an accumulation of saliva and mucus in the 
ducts of the sublingual gland. For two years after the period this 
person consulted me, she was attended both by my professional 
friends and myself, and that without success. During these two 
years that this patient was under the surgical and medical treatment 
both of my medical friends and myself, the following methods of 
cure were adopted in succession : the ranula was very often opened 
with a lancet, and injections of rose-water and sulphate of zinc (five 
grains of the sulphate to the ounce of rose-water) injected by means 
of a syringe, night and morning, into the cavity of the emptied ranula. 
Occasionally, when the ranula burst of its own accord, and left an 
ulcer, considerable portions of the sublingual gland were dissected 
out ; and on one occasion the actual cautery was proposed to be 
employed ; but the patient would not consent to the employment of 
this method of treatment. During the two years the patient was 
under treatment she took occasionally tonics and alteratives, to- 
gether with laxatives, as the nature of her case seemed to require, 
but without any good effect. 

" In these critical circumstances it occurred to me, about five 
years ago, that, if the fluid contained in the ranula were completely 
evacuated, the employment of pressure over the tumor might cause 
adhesion of almost all the internal surfaces of the tumor, except a 
fistulous aperture or apertures, analogous to the sublingual duct, 
through which the saliva would necessarily flow, and by necessary 
consequence a radical cure would be produced, provided that a per- 
manent adhesion of both surfaces of the ranula could be effected. 

" In order to produce such a result, I proceeded to perform the 
following operation. (I must remark that the size of the tumor at 
this period was such as to preclude the possibility of swallowing 
any fluid or solid kind of food.) I introduced a bent needle, armed 
with a ligature, into the ranula, with the view of enabling me to 
render the tumor steady while I was opening it with the lancet, and 
also in order to direct me afterward in injecting the ranula ; this 

* See chapter on Salivary Calculus. 



708 ORAL DISEASES AND SURGERY. 

being done, I procured a common musket-ball of lead, a little flat- 
tened, and having a perforation through it, and through this per- 
foration in the bullet I introduced a yard or so of common tape, 
which was loosely tied around the neck of the patient, while the 
bullet remained in the patient's mouth and pressed by gravitation 
upon the upper covering of the ranula. It is obvious that the tape 
fixed to the bullet served only the purpose of preventing the patient 
from swallowing the bullet while it remained in her mouth. The 
bullet thus kept in the patient's mouth night and day for two weeks 
produced union by inflammation (caused by mechanical pressure) of 
both surfaces of the ranula, except two fistulous apertures analogous 
to sublingual ducts, through which saliva has flowed on each side of 
the frasnum of the tongue ever since ; and this patient has happily 
had no return of her troublesome complaint from that period to this 
date. Now, as nearly five years have elapsed since the cure of the 
ranula, we may hope that the disease will not again return." 

Carcinoma is a condition sometimes met with associated with the 
floor of the mouth ; when the disease is situated in the sublingual 
gland it is, without confusion, to be distinguished from either lipoma 
or ranula. A lipoma affords to the touch the sense of contact with 
fatty tissue. A ranula, however thick its walls, — except in the case 
of the encysted calculus, — may be recognized, by the employment of 
the exploring needle, to be a cyst. A cancerous tumor, especially 
when of limited size, has an expression of solidity pertaining to 
neither of the first two, while associated with it is the specific pain, 
absent in the others. Induration and enlargement of this gland 
when associated with epithelioma of surrounding parts would of 
course have explanation in the association.* 

* See Scirrhus of Tongue ; also chapter on Tumors. 



CHAPTER XXXVI. 



NEURALGIA. 



The term neuralgia is from the Greek roots vsvpov, a "nerve," 
and aXyoq, "pain." It signifies a condition, or an effect, and not a 
cause ; or, if this definition is not absolutely a correct one, the excep- 
tions to the rule it would form are, I am convinced, exceedingly 
rare. For such reasons it is, as commonly employed, a very decep- 
tive term, expressing a condition about as definitely as the term sup- 
puration would convey an idea of the phenomena of inflammation. 

Neuralgia, as the word has been made to have definite applica- 
tion, refers to paroxysmal pains, localized or metastatic, presenting 
no manifestation of any lesion at the seat of pain outside of the single 
phenomenon. 

The pains of neuralgia are mostly, although not exclusively, acute 
in character, are confined to the tract or to the periphery of a certain 
nerve, remit, or more commonly fully intermit, and are only accom- 
panied with tenderness of the part involved when an accidental asso- 
ciate lesion may exist, or when an irritation is so severe or has been 
so long continued as to have reacted on the neighboring vascular 
system. 

When, then, a practitioner Mas his attention directed to a seat of 
pain without apparent lesion, the matter of first importance is an 
appreciation of its cause. To say that such a one has neuralgia, 
and to treat him with nervines, is to say just nothing, and to do 
nothing, except indeed by accident. A first duty is to search for a 
cause, and, if discoverable, remove it, if that be possible. Now, these 
causes of neuralgia are, as I shall show further on, sometimes very 
evident, and very easy of removal ; and it will be seen from the illus- 
trations offered that one, from lack of observation, may utterly fail in 
giving a relief very easily and naturally afforded by another. 

Rheumatism and neuralgia are frequently confounded ; but how 
do the conditions disagree ? Rheumatism is always accompanied 
with vascular perversion ; the pain is not distinctly localized, but is 

(709) 



710 ORAL DISEASES AND SURGERY. 

diffused over a part involved ; it is a soreness, as a general thing, 
rather than a sharp, acute, concentrated pain. Movement aggra- 
vates this soreness, changes in temperature affect it ; it is not parox- 
ysmal, although it may be, and generally is, remitting; in short, it 
has a history, and this history is not difficult to read. 

Gout is another constitutional condition occasionally mistaken for 
neuralgia ; but such a mistake should not occur, for here, too, is a 
history. Gout occurs in the high, indolent liver ; it is decidedly 
inflammatory in its local manifestations. It attacks in preference 
the small joints ; it is accompanied by oedema, by congestion, and 
by enlargement of the veins ; if it is metastatic, the seat of transfer 
presents like vascular phenomena with the original inflammation. 

But is there not a condition — a disease — which is, or might be, 
termed neuralgia ?* — as, for example, gout is a disease with an indi- 
viduality, or rheumatism is a disease. If, without being influenced 
by other than my own observations, I were to answer this question, 
I should incline to say there is not; and my reasons for the denial 
would lie in the fact that I have in one way or another become con- 
versant with so many cases which have stubbornly resisted a long 
course of treatment founded on an abstract neuralgic theory, but 
which have rapidly and readily yielded on the discovery and re- 
moval of some true lesion of which the pain was simply a sympa- 
thetic connection, — as, for instance, otalgia, hemicrania, or even 
sciatica, from an exposed tooth-pulp, from a splinter of foreign sub- 
stance, or from the pressure of an exostosis. It is certainly true 
that there is a class of persons who might be termed neuralgic ; 
these do not belong strictly to what is called the nervous tempera- 
ment, but are the anaemic and prostrafted. A plethoric temperament 
disposes to inflammation, but plethora is not inflammation ; it is only 
a predisposition ; the nervous temperament is only a predisposition. 

*Dr. Anstie, whose monograph on Neuralgia has attracted much attention, 
as well as criticism for and against, advances and defends the position that 
as regards both the seat of what must be the essential part of the morbid pro- 
cess, and the general nature of the process itself, we must possess very definite 
information indeed. In the beginning of his third chapter he says, " I ex- 
pect to convince most readers that the essential seat of every true neuralgia 
is the posterior root of the spinal nerve in which the pain is felt, and that the 
essential condition of the tissue of that nerve-root is atrophy, which is usually 
non-inflammatory in origin." (P. 110 ) There can be no doubt that such 
condition is to be met with as an explanation of peripheral pain ; but such a 
condition is merely one of the neuralgise. 



NEURALGIA. 711 

It cannot be denied that cases called neuralgia, and treated without 
ideas of a definite lesion, do very frequently get well ; but has not 
the indication been accidentally met, just as with the Dewee's car- 
minative we treat the restless child and cure it without definite idea 
of the ailment, having in a single medicine the requirement of various 
conditions ? I think this is so. 

If neuralgia, then, is simply a phenomenon, — simply the expres- 
sion of an immediate or distant lesion, — the preliminary treatment 
must lie in a search after a cause. But is this cause always evident ? 
It is not, at least to our present acquirements : nevertheless, it 
exists, and, failing to discover it, we are compelled to desert princi- 
ples and experimentally treat with the hope of an accidental success. 

Are there predisposing causes of pain-radiation ? Undoubtedly 
there are, and these may, and always should, receive a proper degree 
of attention, as, in guarding against them, it might be that the 
proper lesion would not in itself be sufficient to inaugurate or 
maintain the neuralgia. Thus, of the exciting causes, a damp, 
cold atmosphere is probably one of the most potent. Fatigue, 
over-excitement, excess in drinking, poor diet, the too free use of 
coffee or tea, loss of sleep, costiveness, diarrhoea, — in short, anything 
which interferes with the easy and proper performance of functional 
life. 

In miasmatic neighborhoods, neuralgia frequently assumes the 
periodic type, evidently influenced by the malaria. And it is with- 
out doubt true that the exhibition of quinine will and does, not un- 
frequently, cure such cases. Whether this is because the medicine 
controls the full and complete cause of the trouble, or only removes 
an exciting cause, in the absence of which nature gains the mastery, 
I scarcely know, it being a matter of certainty that it is by no 
means always the case that in the destruction of the periodicity the 
pain is removed. 

Syphilis is another of the exciting causes of neuralgia. I have 
known a patient have great pain from diseased teeth, which could 
be held completely under control, although not cured, by iodide of 
potassium. The pain was undoubtedly from the teeth, as with the 
subsequent removal of these organs the trouble disappeared. 

To epitomize the subject, we might say that in a state of health 
the nervous system represents the poised balance : it is neither 
excited nor depressed ; it works in entire harmony with its require- 
ments. Apply now a source of irritation, and this harmony or 
balance is destroyed. According as the. amount and extent of irrita- 



712 ORAL DISEASES AND SURGERY. 

tion, so are the amount and extent of derangement. Life, says Bichat, 
rests upon the tripod of innervation, respiration, circulation. What- 
ever affects one of these legs affects the whole body. To appreciate 
the phenomena of neuralgia is, then, to appreciate the phenomena 
of irritation, — is to search over the economy until whatever lesion 
exists is exposed and comprehended. 

If a first view is directed to the nervous system itself, we look 
for a lesion in the part which, by the expression of pain, seems most 
markedly implicated. The most decided cases of neuralgia are, 
without doubt, odontalgic. A tooth decays until the cavity contain- 
ing the delicate nerve is exposed ; the neuralgia has the simple, 
single signification of a direct irritation. Exostosis of a tooth-root 
presses on nerves ramifying in the alveolo-dental membrane ; the 
signification is a similar one. 

Let us refer to a neuralgia occurring in the stump of amputation. 
Is the cause not most frequently found in the squeezing and pinching 
of a nerve caught in the cicatrix ? Is it not the same history where 
tumors grow about and press upon some nerve-periphery ? But I 
had meant rather just here to call attention to derangement in nerve- 
substance itself, without associated or influencing lesion, if we might 
be able to find such derangements. Might I instance neuromatous 
expansion as found in stumps, and which are, evidently enough, 
sources of pain ? Are there idiopathic inflammations of nerve-sub- 
stance ? or do nerves in themselves degenerate and ulcerate ? We 
may look at the subject from a still wider stand-point. There is no 
earthly doubt that a pure nervous irritation of the system at large 
may exist. There is certainly an individuality existing in this 
system. It has a mode of action of its own, and this action, as 
remarked by Dr. Wood, is susceptible of exaltation, depression, or 
deprivation in itself, and from the influences of its own peculiar 
agents. But can or do these vicissitudes express themselves ever, 
or even occasionally, in sharp neuralgic pains ? Connected with the 
digestive function we have often nausea and vomiting ; with the 
secretory, disorder of the liver and kidneys; with the respiratory, 
hurried and otherwise irregular breathing ; with the circulatory, a 
frequent and agitated, though seldom full or energetic, pulse. ''As the 
offices of the brain," suggests Prof. Wood, " are various, so also must 
be the signs of its excessive excitation. Irritation in the brain obeys 
the general laws of that morbid affection. If moderate, it exalts the 
healthy functions without otherwise altering them ; if stronger, it 
more or less degenerates the functions ; in great excess, it entirely 



NEURALGIA. 713 

changes or abolishes them. Thus, sensation and perception may 
be rendered simply more acute, or may be deranged, producing 
vertigo, pain, and every variety of disorder in vision, hearing, touch, 
etc., from buzzing in the ears, unnatural coloring of objects, a sense 
of tingling, formication, etc., to complete hallucination. The intel- 
lectual faculties and the emotions may be excited into increased 
vigor, or may be completely perverted, as in delirium and insanity. 
The general overseeing faculty of the brain may be simply stimu- 
lated to increased vigilance, to a more ready and rapid response to 
all the intimations of its dependent functions ; or it may be thrown 
into excessive disorder, evinced by restlessness, jactitation, obstinate 
sleeplessness, etc. The motor faculty may merely impart increased 
activity and energy to the muscles under the influence of the will ; 
or it may throw off more or less completely subordination to that 
principle, and give rise to every variety of spasm and convulsion. 
Finally, all the functions above referred to may be overwhelmed by 
an excess of irritation, and more or less completely lost in stupor 
and coma. This is nerve-irritation, from causes or influences which 
reside in, or in association with, the system, and to be considered 
alone in connection with the system." 

Reactions of vascular perversion on the nervous system are to 
be considered. Coup-de-soleil and apoplexy may be esteemed the 
opposite conditions in such reactions. How frequently have all the 
phenomena of partial compression — headache, giddiness, buzzing in 
the ears, disordered vision, tingling, formication, numbness, drowsi- 
ness, mental confusion, spasms, convulsions, etc. — been quickly re- 
solved and removed by the accidental rupture of a nasal vein having 
communication with a meningeal sinus ! And how happily, when 
similar conditions have come on from long-continued chlorosis, has a 
course of iron relieved them ! Every portion of the encephalic mass, 
every portion of its continuation in the spinal canal, every nerve- 
periphery, requires a certain amount and a certain character of 
blood to keep it in proper poise and nutrition. Too much blood, and 
too nutritious, and we have derangement from over-stimulation ; 
too little, and too poor, we have it from lack of pressure, lack of 
nutrition, and, in many cases, from effusions. 

Derangements in respiration act as predisposing causes to neu- 
ralgia. A patient who labors under an inability to aerate his blood, 
whatever may be the cause, fails to relieve that fluid of certain 
poisonous qualities, which, of necessity, sooner or later must disturb 
the nervous economy. 



714 ORAL DISEASES AND SURGERY. 

Anything and everything, in short, it may be said, which acts as 
a depressant in the vital economy, whether by over-stimulation or 
by undernutrition, is to be thought of, and considered, in neural 
derangements ; overstudy, sensual excess, indigestion, hepatic and 
nephritic diseases, repression of the cutaneous circulation, the de- 
pressing passions, as fear, grief, melancholy ; the employment of 
sedative poisons, as opium, tobacco, chloroform ; living in an atmos- 
phere impregnated with irrespirable gases, — any of these may 
assist some otherwise incapable lesion in determining an attack of 
neuralgia. 

The most extreme case of nervous mania that has ever come 
under my own observation, accompanied with general hyperes- 
thesia and local neuralgia, was in the person of a carter, addicted to 
smoking. For three days this man was uncontrollable by any but 
physical restraint ; at the end of which period, having secured a 
short interval of sleep and quiet, I placed between his lips a pipe of 
the strongest tobacco. I finally cured the patient, making the sec- 
tion of a nerve, and treating him with tobacco and sedatives, just as 
one treats delirium tremens with whisky and sedatives. In this case 
I am entirely satisfied that the local neuralgia was goaded to its 
intensity by the perverted condition of the general nervous system. 
Several cases of similar import I can recall, associated with the 
improper use of opium, and with the abuse of the sexual instincts. 

In the cases of persons long habituated to the use of opiates as a 
relief in neuralgic pain, operations which have considered and which 
have truly relieved the system of the lesion of offense are not apt 
to be followed by the immediate relief anticipated. Here is a point 
in which the most practical experience agrees with certain deduc- 
tions of Dr. Anstie, that " pain involves a lowering of function ;" 
w r hile, on the other hand, it would not seem so reasonable to admit 
that it is " not a hyperesthesia." Pain is of both conditions, and is 
to have such appreciation if it is to have cure. 

The first of the propositions finds demonstration plain enough in 
the exhibitions of the inebriate, w T ho manifests the first symptoms of 
delirium only on the deprivation of the wonted stimulus, his aberra- 
tion having the meaning of exhaustion consequent on over-stimula- 
tion, as shown in what might be termed the synthetical proof of the 
primary demand for stimulation. 

From his own practice the author might cite many interesting 
cases illustrative of the difficulty of affording ease to a patient ad- 
dicted to, and long dependent on, opiates, even where the original 



NEURALGIA. 715 

disease undoubtedly had been cured, — as, for example, in such in- 
stances as the removal of cicatrices or of foreign bodies ; these cases, 
however, are not at all in proof of the neuralgia being a disease in 
itself, but rather the reverse ; the pain is the expression of weak- 
ness, of exhaustion. No lesion remains to be considered. Cure is 
to be found in getting back the lost equipoise. Exactly what this 
lost equilibrium may be called is entirely immaterial. Let it be 
named vaso-motor paralysis, as designated by Dr. Anstie, and let it 
be said that the paralysis is a " direct extension of the original mor- 
bid process from the sensory root to the motor, affecting the original 
fibres in the latter, which are destined to control the calibre of the 
ocular and facial vessels." Granting the premise of neuralgia being 
an expression of the presence of an irritant, or accepting the hypothesis 
of Anstie as to its being a condition of diminished vitality, it must 
certainly be felt that the hypodermic injection of morphia, — of ob- 
tunding agents, — so continuously practiced and recommended, has in 
it only the virtue of covering a wound temporarily from sight and 
calling it well : indeed, it is much worse than this, it is exhausting 
more completely that which is already exhausted ; it is medicating 
an effect and taking no heed of that which is the cause of the effect. 

The meaning, however, is not designed to be conveyed that the 
opiates are not justifiably to be used in neuralgic conditions; pain 
in itself is a cause of exhaustion, and it may prove the lesser of two 
evils to moderate or annul pain ; but opiates are to be employed as 
adjuncts. When we find ourselves forced to rely upon them, the 
confession is extorted that we know solidly nothing at all about the 
case we are so treating. 

In a letter to the London Times, republished in the Medical 
Times and Gazette, Sir Benjamin Brodie expresses his general dis- 
approbation of the habitual use of tobacco, and makes the following 
observations on its deleterious effects : 

" The effects of this habit are indeed various, the difference de- 
pending on difference of constitution and difference in the mode of 
life otherwise. But, from the best observations which I have been 
able to make on the subject, I am led to believe that there are very 
few who do not suffer harm from it, to a greater or less extent. The 
earliest symptoms are manifested in the derangement of the nervous 
system. A large proportion of habitual smokers are rendered lazy 
and listless, indisposed to bodily, and incapable of much mental, ex- 
ertion. Others suffer from depression of the spirits, amounting to 
hypochondriasis, which smoking relieves for a time, though it ag- 



716 ORAL DISEASES AND SURGERY. 

gravates the evil afterward. Occasionally there is a general nervous 
excitability, which, though very much less in degree, partakes of the 
nature of the delirium tremens of drunkards. I have known many in- 
dividuals to suffer from severe nervous pains, sometimes in one, some- 
times in another part of the body. Almost the worst case of neuralgia 
that ever came under my observation, was that of a gentleman who 
consulted the late Dr. Bright and myself. The pains were universal, 
and never absent; but during the night they were especially intense, 
so as almost wholly to prevent sleep. Neither the patient himself 
nor his medical attendant had any doubts that the disease was to be 
attributed to his former habit of smoking, on the discontinuance of 
which he slowly and gradually recovered. An eminent surgeon, 
who has a great experience in ophthalmic diseases, believes that, in 
some instances, he has been able to trace blindness from amaurosis 
to excess in tobacco-smoking ; the connection of the two being 
pretty well established in one case by the fact that, on the practice 
being left off, the sight of the patient was gradually restored. It 
would be easy for me to refer to other symptoms indicating deficient 
power of the nervous system to which smokers are liable ; but it is 
unnecessary for me to do so; and, indeed, there are some which I 
would rather leave them to imagine for themselves than undertake 
the description of them myself in writing. 

"But the ill effects of tobacco are not confined to the nervous 
system. In many instances there is a loss of the healthy appetite 
for food, the imperfect state of the digestion being soon rendered 
manifest by the loss of flesh and the sallow countenance. It is dif- 
ficult to say what other diseases may not follow the imperfect as- 
similation of food continued during a long period of time. So many 
causes are in operation in the human body which may tend in a 
greater or less degree to the production of organic changes in it, that 
it is only in some instances we can venture to pronounce as to the 
precise manner in which a disease that proves mortal has origi- 
nated. From cases, however, which have fallen under my own ob- 
servation, and from a consideration of all the circumstances, I cannot 
entertain a doubt that, if we could obtain accurate statistics on the 
subject, we should find that the value of life in inveterate smokers is 
considerably below the average. Nor is this opinion in any degree 
contradicted by the fact that there are individuals who in spite of 
the inhalation of tobacco-smoke live to be old, and without any ma- 
terial derangement of the health; analogous exceptions to the gen- 



NEURALGIA. 717 

eral rule being met with in the case of those who have indulged too 
freely in the use of spirituous and fermented liquors." 

With such general considerations of the matter, it may prove 
most advantageous to pass to illustrations in the recital of individual 
cases. With the data afforded by such a review, we may with more 
satisfactory premises appreciate the principles of cure. 

Case I. — Mrs. B., the wife of an undertaker, suffered for a long 
time from periodic attacks of pain about the face and head. This 
person, exceedingly quiet and retiring, spent most of her life in 
sunless rooms, surrounded by the melancholy paraphernalia pertain- 
ing to the business of her husband. She was anaemic, and of poor 
general health and spirits. Although this patient had certain bad 
teeth, yet the pain had never seemed associated with them ; indeed, 
so insensible were these organs to ordinary agents of irritation, that 
a diagnosis was founded alone on her general condition and sur- 
roundings, and remedies applied entirely in such direction. Tonics 
were administered, window-shutters were unbowed, exercise and 
amusement, conjoined with generous living, were advised; even 
with this entire change the patient failed to improve, but, on the 
contrary, grew worse. The diagnosis thus discovered to be at fault, 
the teeth were extracted ; still the condition persisted, and the pain 
increased. She was now treated for over a year, the pharmacopoeia 
being exhausted in her case. Called in consultation, and acting on 
the belief of the existence of a special lesion in all such cases, I 
determined, with the concurrence of the gentleman in attendance on 
the case, to make a most careful exploration of her whole system. 
At this period the pain had assumed and continued the impression 
of an iron clamp over the head, terminating beneath, and which 
clamp seemed daily contracting itself. The terror and pain of this 
impression had become so great as to convert the patient almost into 
a lunatic. I found, on inquiry, that her internal organs had been 
most carefully examined, and inferred not to be in fault. My own 
investigations, therefore, were commenced externally. First, was 
there any remaining tooth or teeth implicated ? I examined for 
caries, for pulpitis, for nodules, for necrosis, for supernumerary teeth, 
for exposed cementum, but fully assured myself these organs were 
in no wise involved. I examined the spinal cord, and, through its 
expressions, the encephalic mass ; organically, the trouble could not 
be found reflex from these points. I examined every articulation, 
the line of every artery, vein, and nerve, so far as I might follow 
them. I passed in review every observation and fact which might 



718 ORAL DISEASES AND SURGERY. 

enlighten me, but without success, so far as any discovery of an 
exciting cause was concerned. Finally, I returned to the oral 
cavity. The teeth which had been extracted the year before were 
the molars and premolars of the left superior jaw. Might there not 
possibly have been just the smallest particle of one of these teeth 
left in its socket ? I was making pressure in the canine fossa, when 
the patient made slight complaint; it was the only point which 
yielded difference in sensation. Now, what was this sensation, and 
what did it mean ? It was not pain of which the patient com- 
plained, not discomfort; it was simply difference of sensation. But 
it was the only point which had yielded expression; it was there- 
fore differentially just to infer that here existed something, — the 
lesion, perhaps, of which we were in search. Acting on this hint, 
I obtained the consent of my colleague to make an exploratory tre- 
phine of the antrum, and, on performing the operation, discovered 
that branches of the intraorbital nerve running across the cavity 
had enlarged to the size of knitting-needles. These enlarged nerves, 
of which there were two, I cut away. The patient was immediately 
relieved, and, although three years have passed, she has had no 
recurrence of her neuralgia. 

Case II. — In October, 1868, I treated and dismissed a patient, a 
young lady, who shortened a summer and fall campaign to come to 
Philadelphia for advice concerning neuralgia of the face, and of the 
ear and scalp. She described her agony as being sometimes so great 
that only from chloroform could she get even a temporary relief ; 
had been taking tonics and opiates throughout the summer ; had no 
pain in any of her teeth, although on the upper jaw was a pulpless 
molar. Examining her mouth, my attention was attracted to a 
peculiar overriding of the second bicuspid tooth of the lower jaw by 
the first molar; the employment of a delicate curved probe revealed 
caries of the first of these teeth exposing the pulp ; the tooth was 
extracted, and the distant and apparently dissociated neuralgia in- 
stantly disappeared. 

A tendency to nervous irritability which exists in this patient 
may very well be re-aroused by the presence of the upper dead 
molar ; if this should prove to be the case, she is advised to have it 
extracted. 

Case III. — " Softening of Inferior Dental Nerve ; Exostosis of 
Infra-orbital Canal ; Trephining; Cure. Professor Greene's Clinic 
in the Medical School of Maine. — Mrs. W., aged fifty-four. About three 
years ago, patient began to suffer from pain at the angle of the lower 



NEURALGIA. 719 

jaw on the right side. This was paroxysmal in its character; but 
the attacks were so frequent and severe as to unfit her for usefulness 
or enjoyment. Her sufferings had been much increased during the 
past year, and the pain now affected the whole side of the face, 
being quite severe in the infra- and supra-ovh\ta\ regions. There 
was no tenderness or swelling ; no apparent derangement of the 
general health that was not referable to the local suffering. She 
had undergone most thorough medical treatment, both general and 
local, in the hands of good physicians, with no avail. Hypodermic 
injections of morphine and atropia had failed to afford any perma- 
nent relief. Professor Greene said, that from the fact that there 
was no failure of the general health previous to the local trouble, 
and none now except the debility, fairly attributable to the long- 
continued pain, and also the fact that the various plans of treatment, 
whether alterative or tonic, combined with the most powerful ano- 
dynes, had failed, it was probable that the disease was local in its 
character. Whether the inferior dental nerve alone was involved, 
or whether the main trunk or the fifth pair was diseased, w T as 
doubtful ; but, as the pain was so completely localized at the angle 
of the jaw at the outset, and so remained for many months, the 
probabilities were that the pain along the other branches was reflex. 
At any rate, it was one of those cases where we are justified in tre- 
phining the jaw and exposing the nerve. We might find the nerve 
inflamed or softened, or pressed upon by a little bony tumor pro- 
jecting within the dental canal. Oftentimes these cases were asso- 
ciated with and dependent upon ostitis or caries, but here there was 
no evidence of diseased bone. The two last molars had been ex- 
tracted years before, but the parts seemed healthy. Dr. G-. had 
operated in one case where the nerve and the surrounding bone 
appeared perfectly healthy, but perfect relief followed division of 
the nerve. 

" Ether was given, and a curved incision, with its convexity look- 
ing downward and backward, made over the angle of the jaw, the 
bone carefully exposed, and with a small trephine a button of bone 
removed, exposing the dental canal. The nerve was found so much 
softened as to lacerate readily when the attempt was made to raise 
it from its bed. The exposed portion was all removed, the wound 
closed with silver sutures, and a wet compress applied. The relief 
from pain at this point was immediate and complete. The lady slept 
well without anodynes, and in a week returned home, well, with the 
exception of some pain still existing in the infra-orbital region. 



720 ORAL DISEASES AND SURGERY. 

" At the end of six weeks she returned, complaining of a great 
increase of suffering. The pain was well localized, and entirely 
neuralgic in its character. Ether was again administered, and by a 
curved incision the nerve was exposed at its exit from the infra- 
orbital foramen. It appeared to be perfectly healthy ; but, upon 
cutting away the walls of the canal for half an inch, a little sharp 
exostosis was seen upon the right side, pressing upon and flattening 
the nerve. This was removed, the wound closed, and simple dress- 
ings applied. The relief was immediate and complete." 

Case IV. — Neuralgia of Neck and Arm from Carious Molar. 
— Dr. Hyde Salter, well known in connection with clinical practice, 
had suffered much from attacks of inflammation in the left lower 
anterior molar, which was extensively excavated by caries. At the 
age of seventeen these acute symptoms had ceased for two or three 
years, leaving nothing but a grumbling uneasiness in it. At this 
time neuralgic pains began to extend from the tooth down into the 
neck and left side, and thence over the collar-bone down the left 
arm, — these pains enduring several days and then remitting. There 
was no actual pain in the tooth itself, nor any tenderness in it, nor 
in the adjacent gum, nor any appearance of inflammation. The 
situation of the pain in the neck and clavicular and supramaxillary 
regions was exactly that of the descending cutaneous branches of 
the cervical plexus, and the part of the arm where the aching was 
the most intense and intolerable was at the insertion of the deltoid. 
These symptoms disappeared with the extraction of the offending 
tooth, and have never since returned. 

Case V. — Intense Neuralgia of the Eyeball and Face ; Altera- 
tion of the Color of the Iris; Carious Teeth. — Mrs. C, aged 
thirty, had suffered for ten years from severe neuralgia, affecting 
the left eyeball and left side of the head and face, the iris of the 
affected eye having changed from a deep and bright hazel to a dull 
gray. The left lower dens sapientiae and the first upper bicuspid 
being found badly carious, these were extracted, and the operation 
was attended by a terrible paroxysm of neuralgia ; but after this had 
subsided the patient experienced relief for about three months, 
when, the old pain returning, the second upper bicuspid was found 
to be carious and intensely tender, and upon its removal a consider- 
able exostosis was found on the root. The pain vanished with the 
tooth. — (Guy's Hospital Reports.) 

Case VI. — Neuralgia of Lower Jaw; Necrosis. — M. C, a 
laborer, applied for treatment, complaining of unbearable pain 



NEUBALGIA. 721 

situated about the roots of the inferior central incisor teeth. The 
most careful examination revealed no explanation, and the patient 
was dismissed for the day with an opiate prescription. A second 
examination, and many succeeding ones, failed to yield a diagnosis, 
opiates being continued during the period. At the end of some 
three weeks an inflammation supervened, resisted all treatment, 
and finally terminated in a necrosis, which cast off the two teeth 
with their alveoli; the exfoliation completed, the neuralgia disap- 
peared. 

Case VII. — Dr. Benjamin Rush relates a case of neuralgia in the 
nates, which, resisting other means of treatment, finally yielded to 
the extraction of a tooth. 

Case VIII. — Megrim. — A protege of the Princess of Conde was 
bled in the arm and foot twenty times for megrim of five years' 
standing. It at last being thought advisable to open the jugular 
vein, the princess applied to M. Petot to perform the operation. 
But this surgeon, not seeing the necessity for so frequent depletion, 
begged to examine the mouth, and found in the lower jaw, in which 
the patient had for a long time had pain and numbness, eighteen, 
instead of sixteen, teeth, resulting in a very crowded denture. By 
extracting the second molar on either side, he gave complete and 
permanent relief in twenty-four hours. 

Case IX. — Neuralgia Faciei and Odontalgia from Menstrual 
Irregularities. — A lady of rank (Rayer), long suffering from amen- 
orrhea, was subject to frequent epistaxis, pain in the side, and 
swelling of the abdomen and feet. These symptoms were overcome, 
and for a year she enjoyed good health; but last summer, in conse- 
quence of mental distress, a severe neuralgia came on, which was 
cured for a time, but soon returned with the following curious 
symptoms: every evening the pains recurred, preceded by the dis- 
charge from between the upper canine and bicuspis of the left side 
of a matter which was at first thick, viscid, and bloody, but after- 
ward clear and so profuse as to fill a small vessel. The pains con- 
tinued the whole night. No remedies gave any relief but opiates, 
which suppressed both the pain and discharge and gave sleep. 

Case X. — A nun (Wepser), aged forty, was seized, at one of her 
menstrual periods, with pain in the head, eyes, and teeth. A tooth 
on the left side was extracted, but without relief; the pain passed 
to the right side, and for five weeks, with occasional intervals of 
from half a day to two days, caused much suffering, first on one 
side of the head, then on the other, the principal seat of the pain 

46 



722 ORAL DISEASES AND SURGERY. 

being a space two or three fingers broad on the side of the head. 
When the attacks were violent they were preceded by a strongly- 
marked chill, the throbbing of the temporal artery was very per- 
ceptible, the eye injected, and when the paroxysms were at their 
height flushings were experienced. In the treatment of this case, 
as the teeth were discovered to be not at all in fault, the surgeon 
opened an issue in each arm and a third on the neck, all three of 
which were made to discharge freely. Attention was also paid to 
the nervous system, with a view to give it tone and strength. Not 
much regard was paid to the amenorrhcea, because at such age the 
menses are usually very scant. 

In both the above cases the practitioners failed of a successful 
treatment, and evidently for the reason that, in each case, treatment 
was misdirected. A reflected or radiated irritability of the uterus 
was without doubt the lesion, — an ulcer or other local lesion being 
the offense. 

Case XL — One of the most impressive cases of neuralgia ever 
treated by the author has the following history. A Mr. B., serving 
in the war of the rebellion, received, as near as memory serves to 
recall the case, three gunshot wounds, — one in which a small minie- 
ball passed through the tarsal bones, a second in the arm, a third 
perhaps in the chest ; the exact locations of the two latter are not 
distinctly recalled, as they did not associate with the case. After 
dismissal from the service, and after, upon his return home, being 
engaged for a long period in the occupation of a carter, the patient 
commenced to experience pain in the knee-joint and down the back 
of the leg, this pain during a period of months increasing to such 
extent in severity as to require a constant watch being kept to pre- 
vent suicide. The author feels justified in asserting that seldom is wit- 
nessed greater expression of agony in a human being than was the 
almost constant condition of this man. Spending 1 two months in 
the observation and clinical study of this case, the conclusion eventu- 
ally forced itself upon the mind that associated with the track 
of the ball through the foot existed some lesion of the anterior 
tibial nerve. Not that at this point there was pain, tenderness, or 
indeed expression of any kind, but a diagnosis by exclusion seemed 
to centre the trouble here: the author mentions particularly the 
absence of all signs, because he could find no one to second his 
conclusions or to indorse a proposition to make section of the nerve 
above the ankle. The nerve, however, was exposed and a section 
of an inch removed. Prom the moment of the operation the patient 



NEURALGIA. 723 

was entirely free from his neuralgia, although tenderness about the 
knee upon pressure continued for some little time, while the super- 
ficial portions overlying both malleoli sloughed and remained in an 
ulcerating condition over three months.* 

Affections of the Nervous System dependent on Diseases of 
the Permanent Teeth. — Mr. Salter contributes to Guy's Hospital 
Reports a most interesting paper under the foregoing title, which 
contains much information of direct and practical value. "Disorders 
of this kind," says Mr. Salter, " are divided into those which are 
reflex, secondary, and remote ; and those which are direct, imme- 
diate, and from contiguity. In the former category would rank 
epilepsy, neuralgia, paralysis ; in the latter, local pain, facial palsy, 
some forms of amaurosis, etc. In other instances, such as those in 
which exalted sensibility of the tegumental nerves of the face, or 
erratic pains through the maxillary nerves, are associated with 
toothache, it might be difficult to say whether the phenomena are 
mostly reflex or direct ; they probably comprise both conditions. 
. . . The posterior lower molars are but little removed from the 
tonsils and Eustachian tube, from the parotid region, and from the 
external auditory passage. The fangs of the upper back teeth are 
close to the orbit and its all-important contents ; and more posteriorly 
they approach the spheno-maxillary fossa and fissure. Thus it is 
easy to account for the nervous complications which are directly 
entailed by the spread of inflammation from the periosteum of dis- 
eased teeth. 

"By far the commonest reflex nervous disturbances to which 
dental irritation gives rise are neuralgic pains of the head; and this 
is especially the case where the upper teeth are implicated. In the 

* Nutritive changes in connective tissue consequent on nerve-wounds, 
founded on an observation of one hundred and sixty cases, are referred to by 
Dr. S. Weir Mitchell in his valuable contribution to the study of nerve-lesions, 
"Injuries of Nerves." "In looking over my notes," says this writer, "I 
find that oedema was apt to come on suddenly ; sometimes the swelling came 
and went without obvious cause, and sometimes it was very persistent and 
accompanied with congestion of the skin. In generalized atrophic condition 
of a limb, the connective tissue shared the loss which fell upon the other tissues, 
seeming to disappear quite as rapidly as they. It is, however, indicative of 
the difficulties which surround these cases, that in a single instance I have 
seen a nerve-wound giving rise to an hypertrophic state of the connective 
tissues. The case is so unusual that I have been unable to match it either 
from my own material or from the records of others. Such a condition of 
sclerosis of the areolar tissues is, however, a rare accident of spinal myelins.'' 



724 ORAL DISEASES AND SURGERY. 

supra- and infraorbital nerves, the globe of the eye, the temples, and 
particularly a spot near the vertex, a little on one side (the side of 
the affected tooth), in all these regions 'dental neuralgia' is really 
very common ; and I have observed, not unfrequently, that, where 
the pain has continued long, the integument has become hot, and 
tender, and red. , . . 

" The several branches of the trigeminus appear to be the most 
susceptible of reflex affection caused by the dental irritation of one 
of them ; but next to the different elements of the fifth nerve, the 
branches of the cervical and brachial plexuses are most commonly 
involved. Thus, pains in the neck, shoulder, acromion process, in- 
sertion of the deltoid, or bend of the elbow, are by no means un- 
common, and with them occasionally a loss of motor power, a weary 
sense of fatigue in the flexor muscles, and an inability to grasp 
firmly with the hand. It would really seem that there is occasion- 
ally, and in some individuals, a special and exceptional communica- 
tion between the fifth nerve and those of the arm. Dr. Anstie has 
seen two instances in which wounds of branches of the ulnar nerve 
have caused reflex neuralgia of the fifth nerve. And he remarks 
upon this circumstance, ' That the mental perception of the patient 
should, in each of these cases, refer the pain, not to any point in 
the course of the injured nerve, but to the branches of the trigeminal, 
affords, in my opinion, a strong suggestion that that portion of the 
central nervous system with which the trigeminus is directly con- 
nected, presents some congenital or acquired peculiarity of organi- 
zation.' This idea is fully borne out by what one occasionally, 
but only occasionally and exceptionally, sees in the occurrence of 
brachial neuralgia and paralysis caused by dental irritation of the 
branches of the fifth nerve. 

" Reflex nervous irritation, dependent upon dental disease, is 
most uncertain and capricious in its manifestations. One person 
will suffer much from a comparatively slight cause, while in others 
the same condition more severely developed will produce no such 
result. There is, unquestionably, in some persons a neuralgic diath- 
esis ; and it is not improbable also that, in some individuals, there 
may be a congenital or induced peculiarity in the centric or, perhaps, 
collateral relations of certain nerves, by which the exalted polarity 
of one may be passed on and so reflected upon another with ab- 
normal facility. In persons obnoxious to these forms of neuralgia 
from dental irritation, nothing is so liable to produce an attack as 
exhaustion or depressed nutrition ; and patients will often tell you 



NEURALGIA. 725 

that the attacks only come on when they are very tired, or have 
gone long without food. 

"Pain is only one of the phenomena of reflex dental nerve irrita- 
tion. It may induce muscular spasm, muscular paralysis, paral- 
ysis of some of the nerves of special sense, perverted nutrition. 

"As regards the teeth themselves which excite this exalted ner- 
vous irritability, nearly all their diseases appear capable of causing 
this condition. Thus : 

" Caries, with or without exposure of the pulp ; exostosis ; hy- 
pertrophy of the crusta petrosa ; nodular developments of dentine 
in the pulp cavity ; periostitis, plastic or superlative ; impaction of 
permanent teeth in the maxillary bones ; crowding of teeth from 
insufficient room. 

" Each and all of the above-enumerated abnormities of teeth have 
caused manifestations of reflex nervous irritation, though, as I have 
remarked, they may exist in the severest forms without producing 
any such result." 

Mr. Salter then records a series of cases illustrative of the vari- 
ous pathological conditions referred to, of which the following is a 
brief abstract : 

EEFLEX AFFECTIONS. 

" Facial Neuralgia from Dentine Excrescence in Pulp Cavity. — 
A woman complained of severe neuralgic pains obviously connected 
with an upper central incisor. The pain was of a gnawing character, 
abiding, but not constantly severe ; frequently merely a conscious- 
ness of the presence of the tooth, but at other times sharp and dart- 
ing, flashing up the side of the face, etc., through all the branches 
of the superior maxillary division of the fifth nerve of that side, and 
considerably augmented by sudden pressure, a tap upon the tooth, 
or marked change of temperature. The tooth was apparently sound, 
though somewhat elongated and slightly loose. No exostosis was 
found on the root after extraction, but on making a section of it 
(vertical, from side to side) an excrescence of dentine was dis- 
covered growing from the side of the pulp cavity, and occupying, for 
a short space, more than half its diameter. The removal of the 
tooth, though accompanied with a violent paroxysm of neuralgic 
agony, was followed by a total cessation of the pain, which never 
recurred. 

" Cranial Neuralgia from an Impacted Canine Tooth. — Miss 



726 ORAL DISEASES AXD SURGERY. 

B bad ' cut ' all the permanent teeth in due course and position, 

except the left upper canine, the proper space for which was oblit- 
erated by the contact of the lateral incisor and first bicuspis. At 
the time when the right upper canine appeared, a hard swelling was 
noticed in the palate, on the left side, and toward the front of the 
mouth, and this slowly developed into a prominent rounded ridge, 
extending obliquely behind the left incisors and left first bicuspis. 
No inconvenience was felt up to the age of eighteen, when severe 
headache, confined to a spot on the vertex toward the left side, 
attended by local heat, etc., temporarily relieved by pressure, made 
its appearance. This headache, which was recurrent in its nature, 
lasted until the patient was twenty-six, no actual pain being felt in 
the impacted tooth, although the region about it became hot and 
tender upon the supervention of the headache. The removal of the 
tooth by Mr. Cartwright — an operation involving much chipping 
away of the bony cavity in which it was imbedded — was followed 
by immediate and permanent relief, thirty years having elapsed 
with no return of the symptoms. 

"Intense and General Neuralgia from Exostosis on Fangs of 
Teeth. — Miss B. P. had gone through her first dentition with- 
out trouble, but, on account of some crowding on the advent of the 
permanent teeth, an upper and lower bicuspis on either side were 
extracted to make room. During adolescence she was attacked by 
neuralgic pains, at first confined to branches of the trigeminus, but 
afterward extending to the arms, legs, etc., indeed, nearly the whole 
body. The teeth, though apparently sound, had a tendency to 
elongate and spread, especially the upper incisors, with which the 
pain was at first chiefly associated. The offending teeth always 
gave pain on being slightly struck. Mr. Bell removed, from time 
to time, the teeth most obviously connected with the neuralgia, in 
each instance with temporary relief of the suffering, and in every 
case the fangs of the extracted teeth were found incrusted with 
nodular exostosis, though the teeth themselves were free from caries. 
When Mr. Salter saw Miss P. (in 1851), only the two lower left 
bicuspids remained, and these were causing a continuance of the 
neuralgia, which ceased after their removal. On the fangs of both 
these teeth were the expected nodules of exostosis. This patient is 
stated to have been remarkably anaeinic, the gums being • like wax 
stained of the palest pink/ and the alveoli remaining white and 
bloodless for some seconds after extraction before blood enough 
oozed from the broken vessels to partially fill the hollow sockets. 



NEURALGIA. 727 

11 Neuralgia of the Arm from. Carious Teeth and from undue 
Pressure of Artificial Teeth. — In the case of Mrs. E., caries of 
any of the lower teeth on the left side has been immediately followed 
by severe neuralgic pain at the spot, small and circumscribed, on the 
front of the left forearm, about two inches below the line of flexion. 
Having now lost all her teeth, and wearing a complete artificial set, 
whenever the lower denture hurts the jaw on that side, the same 
symptom is manifested. The right side has never been similarly 
affected. 

" Chronic Trismus from Impaction of Lower Dens Sapientise. — 
In a man aged twenty-three, with large teeth and comparatively 
small maxillary bones, the lower wisdom-teeth were imbedded, and 
unable, from want of room, to come into place. The result was re- 
current pain and swelling within the mouth, followed by a sudden 
attack of ' lock-jaw,' apparently caused by contraction of the left 
masseter muscle, which, after four months' duration, was cured by 
extraction of the left second molar, the wisdom-tooth being out of 
reach. The posterior fang of the extracted tooth was much eroded 
by absorption. 

" Wry-neck from Carious Teeth of Lower Jaw. — A young woman 
whose head had, for more than six months, been drawn down nearly 
to the left shoulder, with considerable pain, was relieved in a few 
days by the removal of a stump and a partially decayed tooth from 
the left side of the lower jaw. 

" ''Epilepsy from Carious Tooth. — A boy, aged thirteen, under the 
care of Dr. Kamskill, had frequent attacks of epilepsy, occurring 
about seven or eight o'clock in the evening. Examination detected 
1 a molar tooth considerably decayed, with a swollen gum around 
it, and partly growing over into the cavity.' It was not very tender 
to the touch, nor did the examination give rise to toothache. The 
extraction of this tooth was followed by cessation of the fits. 

" Tetanus from Mechanical Irritation of the Pulp. — The case of 
a gentleman (quoted from Tomes' 's Dental Surgery), who, having 
broken off a front tooth, went immediately to a prominent dentist in 
Paris and had an artificial crown pivoted with a gold peg upon the 
fang. After severe pain for four or five days, trismus set in, and was 
soon followed by tetanus and death. 

u Neuralgia of Face, Neck, and Arm, with Partial Paralysis of 
the latter, from Carious Wisdom- Tooth. — Miss W. 'was suffer- 
ing from constant aching pain in the left side of the face and neck, 
and in the left arm. The pain sometimes became intensely severe. 



728 ORAL DISEASES AXD SURGERY. 

The arm had lost nearly all muscular power.' These symptoms, 
after resisting all medical treatment for two years, disappeared in a 
few hours after the removal of the tooth. 

"Amaurosis caused by Crowding of Teeth. — In this case (re- 
ported by Mr. Hancock in the Lancet of 1859, p. 80), a boy, aged 
eleven, whose sight had been previously unimpaired, found upon 
waking one morning that he was entirely blind. About a month 
afterward he was admitted to Charing Cross Hospital, where it was 
discovered that his teeth were ' much crowded and wedged together ; 
the jaws, in fact, not being large enough for them/ Accordingly, 
two permanent and four milk molar teeth were extracted, and ' on 
the same evening the boy could distinguish light from darkness, and 
on the following morning could make out objects. From this time 
his sight rapidly improved, and he was dismissed cured on the 28th 
(eleven days after), the only treatment beyond the removal of the 
teeth being two doses of aperient medicine.' 

"Dr. Watson ('Lectures on Physic,' fourth ed., vol. ii. p. 351) 
mentions a very similar case. But the blindness was confined to 
one eye ; it recurred two or three times, and was on each occasion 
cured by tooth-extraction. 

" Deaf ness from Carious Teeth. — Mr. Cattlin reports the case of 
a lady who had for about three months suffered acute pain in a 
diseased right lower molar, and in the corresponding ear and side 
of the neck, and who had been deaf for four clays. 'The inflamed 
tooth was extracted, and hearing returned within an hour after the 
operation." 

"Perverted Nutrition from Dental Nervous Irritation. — Under 
this heading three cases are quoted from Mr. Hilton's work (•' On 
the Influence of Mechanical and Physiological Pest,' etc.), in which 
the tongue was decidedly furred only on the side corresponding 
with carious or painful teeth ; one in which the hair of the left 
temple was bleached by unilateral neuralgia, arising from a carious 
molar tooth; and one in which ulceration of the auditory canal, ac- 
companied with offensive discharges from the ear, and enlargement 
of one of the cervical glands, was traced to a diseased lower molar 
on the same side, and subsided soon after the extraction of the 
tooth." 

In a paper on " Affections of the Eye from Dental Diseases," read 
before the Missouri State Medical Association by Dr. H. Z. Gill, the 
following instructive case is cited : 

"Mr. F. S., of Illinois, aged thirty-three; Irishman by birth ; farmer 



NEURALGIA. 729 

by occupation. Patient was sent to me by a medical friend, Feb. 12, 
1872. The history of the case, as he gave it, is as follows. In the 
early part of the winter of 1870-11, he was attacked with neuralgia 
of the head and face. It was very severe at times, and continued 
so till the middle of the summer following. The neuralgia affected 
both sides of his head, and his vision to such an extent that he 
could not. read. After the pain left him, in the middle of summer, 
his sight improved. In December, 1871, he was again attacked 
with neuralgia of the head and dimness of vision. Before he came 
to me he had been under treatment for the neuralgia, but I believe 
nothing had been done to relieve the amblyopia. He could scarcely 
seCwell enough to go on the street with safety ; could make out No. 
16 of Jaeger's test-types. He had been able to sleep but little for 
several weeks, on account of the severe neuralgia. Ophthalmoscopic 
examination of the eye showed retinal effusion ; the retinal artery 
was very indistinct. The painful points of Yalleix (points of dou- 
leureux) were well marked, more especially on the left side of the 
head. The patient having lived in a region of country where ague 
at times prevails, I was prepared to learn that his treatment had 
been largely antiperiodic. I now sought for some definite source of 
irritation, inquiring first concerning his teeth, to which his answer 
was that he had no toothache, that his teeth were good. I then 
examined them by inspection, and by percussion with the handle of 
the forceps, yet elicited nothing, except that the teeth were not at all 
painful ; but there was decay in some of them at the margin of the 
gum. Having myself suffered from sensitive dentine, I determined 
to examine more carefully and minutely in the decayed spots. When 
he came again, in a day or two afterward, I made an examination 
of each tooth, and was rewarded by finding what appeared to be 
exposed necrosis of the alveolar process of the superior maxillary 
bone of the left side, but which proved to be a deposit of tartar, as 
large as the little finger-nail, attached to the fangs of the first and 
second molar teeth, the gum being intact around the necks of the 
teeth. I again percussed these teeth with considerable force before 
the patient acknowledged any soreness connected with them. I 
advised him to have them removed immediately, believing them to 
be the source of the neuralgia, and this latter the cause of the 
amblyopia. 

" After two or three days' consideration, he consented, and on the 
16th I extracted, at the first sitting, the first and second molars and 
the second bicuspid. On examination of the teeth I found extensive 



730 ORAL DISEASES AND SURGERY. 

ulceration around the fangs of the molars, extending in some degree 
to the second bicuspis. Believing the dens sapientiaB not to be im- 
plicated, it was not extracted. Three or four days later, I extracted 
the first bicuspis, believing that it was somewhat involved. Im- 
provement of the neuralgia and amblyopia commenced at once. 
On the 21st he read No. 14 of Jaeger, and on the 24th he read No. 
6. His general condition steadily improved. 

" March 4. — Reads No. 2 with some difficulty. Went home March 
8 and returned March 13. Has had pain in his head only a part of one 
day, he thinks from riding in the wind ; reads now No. 2 with consider- 
able ease. Sleeps well. Called twice afterward, and went home 
on the 21st of March. After the extraction of the teeth, he called 
to mind the fact that about eight years since he had received a blow 
on his jaw while breaking a colt. The face was swollen for a few 
days and quite painful, but all uneasiness soon disappeared ; and he 
had entirely forgotten the circumstance until reminded of it by the 
extraction of the teeth. 

"In one part of the 'field of vision' there was greater defect 
than in the remainder ; and evidently, from the appearance of the 
fundus, there was, early in the case while under my care, retinal 
effusion. The specimens of teeth are preserved. The rapid im- 
provement must be ascribed almost entirely to the extraction of 
the teeth, thus removing the source of irritation." 

From the illustrations given, it will be inferred that the removal 
of any discovered lesion of irritation is the primary indication in 
every case of neuralgia. The idea has been advanced that there is 
seldom or never a neuralgia proper, but that such pain is simply an 
expression. It is unfortunately the case, however, that too often 
we are compelled to discover our weakness in a search after causes, 
and are thus rendered unable to treat a case scientifically, but are 
driven to empiricism. Even yet, however, we may render more 
than an accidental service ; and the principle on which we would 
found such treatment is that of soothing and quieting, either as ap- 
plications would refer to the system at large, or to the particular 
part involved. Nervines, where there is general nervous disturb- 
ance, independent, so far as we discover, of other derangements, 
will be found sometimes to act very happily. The tinctures of va- 
lerian and gentian, in equal proportion, given in tablespoonful doses, 
make a fine combination. Bromide of potassium, where it seems 
necessary to keep up a continuous impression, is given with advan- 
tage in doses of ten grains, dissolved in a wineglass of water, from 



NEURALGIA. 731 

two to ten times a day. If administered, however, in a paroxysm, 
forty to sixty grains will be found not too much, and it sometimes 
will be well to combine with it small doses of opium or morphia. 

R. — Potassii bromidi, gr. xx ; 

Morphias acetatis, gr. £ to J, according to severity of pain ; 
Aquas, ^j. M. 
To be repeated as required. 

Valerianate of zinc is a favorite preparation with many practi- 
tioners. It may be made into pills with conserve of rose, or any 
preferred vehicle, each pill to contain from one-half to a full grain, 
to be given twice or thrice a day. 

Tincture of Indian hemp is prescribed in doses of five drops, re- 
peated three times a day. 

Where there is disturbance of the visceral health, it has been 
found occasionally successful to produce rapid but moderate saliva- 
tion. 

Aconite made into quarter-grain pills, and administered cau- 
tiously, three or four times a day, is recommended. 

Digitalis in tincture, or the tincture of veratrum viride, in condi- 
tions of undue circulatory excitement, exhibited in five-drop doses 
until such excitement is subdued, will sometimes quickly relieve the 
pain. 

Colchicum, where there is a supposed gouty association, may 
always be employed. The wine of the root is the best preparation. 

In rheumatic neuralgia, or pain associated with a rheumatic con- 
dition, the following formula will be found very reliable ; certainly 
so, if some other existing lesion is not too antagonistic : 

R. — Potassii iodidi, ^ss ; 

Extracti belladonnas, gr. v j ; 
Yini colchici radicis, ^ss ; 
Tincturas guiaici ammoniatas, ^vj ; 
Aquas cinnamomi, gvj. M. 
Sig. — A tablespoonful to be taken in a wineglass of water three 
times a day ; if it should purge, five drops of laudanum may be 
added to each dose. 

Arsenic is frequently used with decided benefit. It may be ex- 
hibited in granules of the twentieth of a grain three times a day. It 
acts well in cutaneous neuralgia. 



732 ORAL DISEASES AND SURGERY. 

Donovan's solution — the liq. hydrarg. arsen. et iod. — is a favorite 
with many practitioners. Dose, five drops three times a day, avoid- 
ing salivation. It is an alterative, having a variety of significations. 

In all cases associated with lassitude and anaemia, the following 
may be prescribed : 



Or, 



Or, 



R. — Elixirii gentianae ferratse, §vj. 
Sig. — Teaspoonful four times a day. 

R. — Tincturae ferri chloridi, gj ; 
Quiniae sulphatis, 3j. M. 
Sig. — 15 to 20 drops three to four times a day. 

R. — Syrupi ferri pyrophosphatis, ^vj ; 
Quiniae sulphatis, 3j. M. 
Sig. — Teaspoonful four times daily. 

Opium and ether, given in full doses before a paroxysm, with ten 
or fifteen grains of quinine administered after the pain has ceased, 
will, it is asserted, at once make an impression, and frequently 
abridge the next paroxysm. Success is claimed for the exhibition 
of opium to the production of narcotism. Such treatment is only, 
however, commendable as an occasional expedient. 

Muriate of ammonia, in doses of half a drachm three or four times 
a day, has been given with advantage. A very soothing effect is 
produced by placing a lump of the ammonia on a burning coal and 
thus impregnating the atmosphere of a room. 

Oil of turpentine is frequently applauded by English practitioners. 
It may be given in doses of from one-half to a full drachm. 

Chloroform, or chloroform combined with camphor, is recom- 
mended. A formula used by Dr. Wood is as follows: 

R. — Chloroformi, f§ij ; 
Camp horse, 3j- 
Mix with the yolk of an egg and 3yj of water, and direct a table- 
spoonful to be taken every half- hour, every hour, or every two 
hours, according to the urgency of the case, until relief is obtained, 
or some decided effects are experienced from the medicines, either 
on the stomach or brain. Or the chloral hydrate may replace this. 

Vermifuge medicines are frequently prescribed with benefit, par- 
ticularly in the case of children ; parasites frequently keeping up an 



NEURALGIA. 733 

irritation, although presenting no definite signs. Of these medicines, 
one of the very best is the combination of spigelia and senna. 

R. — Syrupi spigelian et senna?, giv. 
Sig. — Teaspoonful doses three times a day. Four ounces will 
commonly be found enough to destroy any worms which may be 
present in the intestines. 

Cathartics are generally indicated in spasmodic attacks of neu- 
ralgia; especially is this the case when there is costiveness, furred 
tongue, sick headache or stomach, giddiness, etc. It is generally 
satisfactory practice to precede the purgation with a few quarter- 
grain doses of calomel. The character of the purgative is to be 
influenced by the condition of the patient. Sulphate of magnesia is 
generally found applicable. Blue mass, colocynth, and jalap, or the 
compound cathartic pill, I have mostly found objectionable. Where 
febrile disturbance is present, particularly do I think this combina- 
tion will be found to do much more harm than good. The ordinary 
Seidlitz powder, repeated three or four times within the day, is a 
very happy and really refreshing medicine. If it should not do good, 
it will certainly do no harm. 

Strychnine is an empirical anti-neuralgic medicine of much repu- 
tation. It may be prescribed in quantities of two grains, divided 
into eighty pills, one to be taken three times a day. 

Of local remedies there is a great variety. A formula long cele- 
brated under the name of Rauque's liniment, is as follows: 

R. — Extracti belladonna?, 9ij ; 
iEtheris, 3j ; 

Aqua? lauro-cerasi, ^ij. M. 
Sig. — Let it be rubbed on the part and saturated flannel be ap- 
plied. 

The endermic application of morphia is a common practice. The 
medicine may be used on a blistered surface, or subcutaneously 
injected, — syringes for the latter purpose being made by all instru- 
ment-makers. To make a subcutaneous injection, it is only neces- 
sary to thrust the needle-point of the syringe into the" rete mucosum, 
or it may be passed completely beneath the skin into the underlying 
cellular structure. 

Hot and moist applications are generally found of much service 
in quieting pain, — the part to be enveloped in old and loose flannel, 



734 ORAL DISEASES AND SURGERY. 

and evaporation prevented by an investment with oiled silk or other 
material. 

In affections of the fifth pair, Dr. Richab, of Strasburg, attributes 
great good to one grain of quinine and two of common snuff, intro- 
duced into the nostril of the painful side. It is said in many cases 
"to act like a charm." 

Professor Charles Meigs introduced, several years back, a plan 
of treatment with sulphuric ether, which has yielded greater tem- 
porary success than anything else I have ever tried. He confused 
the nerve-currents by taking a piece of sponge saturated with ether, 
and, by a continuous but irregular round, touching, here and there, 
different neighboring surfaces, until the pain would disappear. If, 
for example, the pain was in the forehead, he would touch over the 
supraorbital nerve, over the infraorbital, over the anterior dental, 
over the facial, over the cervical, — alternating the touches to these 
parts for a period varying from five minutes to half an hour. In 
most cases the pain will, for the time, be relieved. 

Creasote, much diluted in simple cerate, is sometimes found very 
useful as a local obtunder, — five drops of creasote to the ounce of 
cerate or lard ; to be rubbed over the affected part, little by little, until 
relief is obtained. 

Dr. Kirby directs a liniment made of one drachm of tincture of 
aconite to seven of fresh palm oil, or with two ounces of camphor 
liniment, — a half drachm of the former, or double the quantity of 
the latter, to be rubbed in twice or thrice a day, according to its 
effects. It must be watched, however, as the medicine is cumula- 
tive; if its poisonous effects appear, stimulants are to be given. 

Dr. Grave's neuralgic plaster is compounded as follows: 

B. — Pulveris opii, 9ij ; 
Camphors, 3ss ; 
Picis Burgundies, q. s. M. 
Stupe the parts with warm water before applying it. 

Cazenave's pomade is thus made : 

B. — Chloroformi, 5j ; 
• Potassii cyanidi, Jijss 5 

Adipis, giij ; 
Cerae albas, q. s. 
Rub into the part a piece of the ointment the size of a pigeon's 
egg, and cover with oilskin. 



NEURALGIA. 735 

" Cases treated successfully by the Spine-bag. By John Chap- 
man, M.D., M.R.C.P., M.S.C.S., Physician to the Farringdon Dis- 
pensary. — The cure of neuralgia, whether the disease be treated 
by drugs given internally, or by application of various kinds at the 
seat of pain, or by the two methods conjointly, is confessedly almost 
always difficult, and in a large proportion of cases impossible. The 
cases reported below have been treated by a method altogether new. 
By stating each case with extreme brevity, I am enabled to present 
at one view within a small compass the results of several experi- 
ments ; and I do this in the hope that they may produce such an 
impression on the minds of professional readers as may impel them 
to acquaint themselves with the pathological and therapeutical prin- 
ciples of which these results are an expression. I shall hereafter 
publish an exposition of these principles, illustrated by reports of 
cases in extenso, and shall then give a full description of the treat- 
ment adopted. 

"1. Facial Neuralgia. — T. H., a gentleman, aged thirty-five, who 
had been suffering during the previous fortnight, requested my 
advice March 18, 1865. He was in great pain, which had been 
continuous from the previous day, and which had wholly deprived 
him of sleep. The pain was chiefly on the right side of the face 
and head ; but during the morning preceding my visit the left side 
had become invaded. The affected parts were very tender, and 
somewhat swollen. The head was rather hot, the face flushed, the 
tongue thinly coated with whitish fur ; pulse 92, full and strong. 
Several medicines prescribed by two physicians in succession had 
proved of no avail. 

"I applied a ten-inch spinal water-bag, containing water at 130° 
F., to the cervico-dorsal region, and shortly afterward left the pa- 
tient's room. Within half an hour I returned, when I found him 
asleep. The treatment was continued for two days by means of 
heat; afterward I used ice (at first in the lumbar region) ; and from 
the time he first fell asleep he continued free of pain, which has not 
since returned. 

" 2. Facial Neuralgia. — Fraulein S., aged about twenty-five, con- 
sulted me February 3, 1867, on -account of neuralgia affecting the 
infraorbital and dental branches of the trifacial nerve. The pain 
was not confined to one side of the face, but was sometimes most 
acute on one side, sometimes on the other; it increased at evening, 
and kept her awake the greater part of each night. She had been 
suffering in this way for about three weeks before I saw her. Her 



736 ORAL DISEASES AND SURGERY. 

general health was good. The affected parts presented no trace of 
hyperemia. 

" She was treated by means of ice, and experienced almost imme- 
diate relief. After three days of treatment she felt and slept very 
much better; and before the end of the fifth day the pain had wholly 
ceased. Nearly a year afterward she told me that it had never 
returned. 

" 3. Facial Neuralgia. — Mademoiselle M., aged twenty, consulted 
me in August, 1867, when she was suffering from acute facial neural- 
gia, the chief foci of which were the infraorbital foramen, and the 
mental foramen of the right side. The extreme pain came on in fits, 
sometimes at 8 a.m., sometimes at 2 p.m., but between the paroxysms 
the face continued to ache, and at times the patient had pain at the 
back of the head. She had suffered in this way about a fortnight 
before coming to me, and had several similar attacks during the 
preceding year. 

" The treatment consisted in the application of the double-col- 
umned hot-water bag. The malady was immediately subdued : no 
distinct paroxysm occurred after the first application of heat ; all 
pain rapidly and completely subsided, and since that date has not 
returned. 

"4. Dental Neuralgia. — A. W. B., a Russian gentleman, suffer- 
ing from dental neuralgia, consulted me in September, 186*7. The 
malady was chiefly confined to the teeth of both upper and lower 
jaw, but no particular tooth or teeth seemed to be especially affected. 
The pain was intermittent, and so severe as to interfere seriously 
with the patient's daily occupation. No cause of the disorder, which 
had continued some weeks, could be discovered, and the face, so 
far from showing any sign of hyperemia over the seat of pain, 
seemed cooler than normal. In the course of the first day of treat- 
ment by means of the spinal ice-bag, the pain was completely sub- 
dued ; the cold was persisted in for some time, and during the 
remainder of the patient's stay in England he continued free from 
suffering. 

" 5. Dental Neuralgia. — H. E., female, aged twenty-one, suffering 
from violent and continuous pain, spreading over the teeth and gums 
of both the upper and lower jaw, consulted me, January IT, 1868. 
The pain was most intense in the lower jaw and on the left side ; 
she had intense headache also. The forehead and cheeks were 
notably hotter than normal, and she complained of great heat in the 
roof of the mouth as well as in the gums, — which were swollen and 



NEURALGIA. 737 

sore. During the previous week she had had several teeth stopped 
with gold ; one of them became most especially painful, and there 
was threatening of an abscess at its root. 

" The treatment consisted in the application of cold across the 
occiput, and of heat over the ilio-spinal region, — in the first instance 
separately, and afterward simultaneously. The pain was speedily 
and completely annulled ; it recurred, and was again annulled by 
the same method on several occasions. The patient volunteered 
the statement that during the application of the heat her mouth 
became perceptibly cooler. 

" 6. Facial and Brachial Neuralgia. — Mary A. T., aged forty-four, 
first consulted me at the Farringdon Dispensary, December 28, 1867, 
when she was suffering from neuralgia of the right side of the head, 
face, and neck, and along the right shoulder and arm, extending to 
the fingers. The right half of the tongue was also affected. The 
pain, which was exactly limited to the median line, was described 
by the patient 'like as if something is pulling the flesh off the 
bone, it's so dreadful, and sometimes as if the parts were screwed 
up in a vice.' 

" She was treated by means of ice applied along the whole spine. 
She improved immediately and rapidly, and as early as January 
15, informed me that she had not had ' a bit of neuralgia ' during 
the whole of the preceding week. Up to this date (February 29) 
the pains have not returned." 

Facial Neuralgia from Exposed Tooth Pulp. — Mrs. H. had suf- 
fered for several years with frequent intense and persistent facial 
neuralgia ; had been under the care of four physicians ; taken most 
of the sedative, antispasmodic, tonic, and alterative remedies which 
could be named; had been forbidden to go out of the house after 
sundown ; was not allowed to put her hands in cold water, etc. 

When consulted in reference to her condition, I requested that a 
thorough examination of her teeth should be made by a competent 
dentist, with a view of ascertaining if the trouble did not originate 
there. This was acceded to, but reluctantly, because no pain had 
been felt in the teeth. It was, therefore, with some show of gratifica- 
tion that I was assured subsequently that the teeth were all sound. 
I begged, as a special favor, another and more thorough examination, 
which, very much to my gratification, discovered an exposed pulp. 
This having been treated, the neuralgia disappeared, and has not 
since returned, a period of two years having elapsed. — {J. W. White.) 

Surgical Interference by Operation. — Interference by direct 

47 



738 ORAL DISEASES AND SURGERY. 

operation has not, as a general thing, been so satisfactory as could 
be desired. 

Operative surgery in neuralgia refers to the division or resection 
of nerves. In facial neuralgia, where such interference is most 
frequently practiced, the history of the majority of cases has cer- 
tainly not made sufficient offset to balance the risks incurred. It 
is undoubtedly true that cases occur where it would seem that 
nothing else can be done. But when sections are made of healthy 
nerve-cords one should be well satisfied that he has an otherwise 
irremediable condition in the nerve-substance external to his line of 
section. Following the history of reported cases from nerve-section, 
the inquirer will often have occasion for surprise at the difference 
between the actual and the descriptive results. And this must 
continue to be the case so long as operations are made without 
proper diagnostic perceptions; not that operative means are to be 
discountenanced, but it may with propriety be assumed that a sur- 
geon should find the indorsement of operative means only in a diag- 
nosis which discovers to him the true seat of the lesion of offense. 
As an example of the heroic practice occasionally pursued in this 
direction, both in our own country and in Europe, the following 
may be cited from a report in Gurer's " Progress of Surgery" 
(Berlin, 1863-65). The patient, a woman, submitted to various 
sections of the supra- and infraorbital nerves for a period of five 
years, but, finding no relief, repeated extirpations of the cicatrices 
were made, the common carotid tied, the ascending ramus of the 
lower jaw trephined, and the inferior dental nerve exsected, to- 
gether with the mylo-hyoid and lingualis, causing necrosis of the 
bone, which had to be removed to the articulation. Five months 
later the neuralgia returned, when the infraorbital nerve was ex- 
sected nearly to the foramen rotundum. This was followed by an 
osteoplastic resection of the upper part of the superior maxillary 
bone, but saving the alveolar process as in Langenbeck's operation. 

In another German case ( Vierteljahrsschrift filr die practische 
Heilkunde) the powerful galvano-caustic apparatus of Middeldorpff's 
was employed, at once destroying everything in the sphenomax- 
illary fossa, being followed by a gush of blood from the internal 
maxillary artery, which instantly filled the orbit and all surrounding 
tissues. 

For operations practiced, and the mode of performing them, see 
chapter on Resections. 

Anomalous Nervous Disturbances from Diseased Teeth. — As a 



NEURALGIA. 739 

continuation of the subject of reflex or associate disturbances, it may 
not be without advantage to add the following series of clinical ob- 
servations, abstracted from various journals which from time to time 
have come under the observation of the author : 

"Dr. B., a dentist, consulted me in reference to his eyes, which 
'would not,' as he expressed it, 'focus together:' could see dis- 
tinctly with either eye, but not with both at once ; was unable, in 
consequence, to practice his profession ; had consulted several phy- 
sicians ; been blistered, cupped, and had various applications made 
to the eye, but it was gradually growing worse. The pupil of the 
right eye was very much enlarged. 

"I pronounced a carious and diseased first superior molar to be 
the exciting cause. It was extracted, with almost immediate relief 
and a permanent cure." — {Dr. J. W. White.) 

Facial Paralysis. — Dr. Ghas. Bacon reported to the New York 
State Medical Society the following interesting case of facial paral- 
ysis : 

" The paralysis occurred first on the left side, and was caused 
probably by irritation of the facial or seventh nerve, by the erup- 
tion of the dens sapientiaB of the upper maxilla of the same side, 
and exposure to cold. The swollen gum was freely excised, mus- 
tard pediluvia were employed, active catharsis procured, and the 
camphorated liniment with tincture of opium applied to the mas- 
toid region and to the angle of the jaw, and subsequently electro- 
magnetism to the same region was resorted to, followed by a blister 
to the mastoid region, the denuded surface produced by it being 
sprinkled, twice a day for two days, with one-eighth of a grain of 
strychnine, and then a few doses (fifteen drops) of a solution of 
three grains of strychnine in §j of alcohol were taken. At the end 
of some seventeen months the paralysis had entirely disappeared. 
For about ten months the patient enjoyed uninterrupted good health, 
when he was again attacked with facial palsy of the right side. 
The gum of this side was swollen. A treatment somewhat similar 
to that pursued in the first attack was directed. At the period when 
the report was drawn up, about four weeks from the date of the 
second attack, the paralysis was lessened in extent, and the general 
health of the patient was good. The gum was less swollen, but the 
tooth had not yet made its appearance." 

In Mr. Waite's little book on " The Gums," p. 29, are recorded 
ten cases of paralysis from pressure upon the maxillary nerve, one 
being of the leg, the other of the arm. 



740 ORAL DISEASES AND SURGERY. 

" Neuralgia with Deafness, cured instantaneously by the Extrac- 
tion of a Tooth. — M. Ed. Vautier records {Gazette des Hopitaux) a 
case of such character. The subject of it was a very nervous, slender 
woman, who had suffered for about four months with intense 
neuralgic pains, radiating through almost all the teeth, and also 
the muscles of the anterior region of the left side of the head. 
There was constant lachrymation of the left eye, and from the mo- 
ment of the attack complete deafness in the ear of the same side. 
A number of physicians had been consulted, and sulphate of quinia, 
flying blisters, and atropia, in succession, tried without giving 
relief. 

"When seen by Dr. B., she was suffering severely; had long been 
deprived of sleep, and could not chew her food. The teeth were 
examined with care, but no one could be found carious. The wisdom- 
tooth on the left side seemed, however, slightly painful on being 
touched, and loose. She was advised to have this tooth extracted, 
but, with some temper, refused. However, some days afterward, her 
physician again advising it, she consented, and the tooth was ex- 
tracted by M. Yautier. The pains at once ceased, and her hearing 
was restored. A month has since elapsed without any return of her 
complaint. She seems to be permanently cured." — (Dental Cosmos.) 

" Cases of Convulsions arising from Carious Teeth. — St. Bar- 
tholomew's Hospital. — Notes furnished by Mr. Alfred Coleman : 

" Case I. — L. C. G., aged seven years, a moderately healthy-look- 
ing child up to the age of four years and a half, when he had scar- 
latina severely, followed by glandular swellings. About four months 
since he was observed to avoid using his fingers, and would attempt 
to take up a cup between the backs of his two hands, for which his 
mother, thinking it was a childish trick, always scolded him, and 
tried to make him take it up in the proper way, but without much 
success. Fancying his right arm was diminishing in size, she took 
him to Mr. Coote, who sent him to Mr. Coleman to examine his 
mouth. This was on a Saturday. In the afternoon of the same 
day, after having been seen by Mr. Coleman, the child was attacked 
with a fit of what his mother described as shivering in the right 
arm, the arm and fingers being drawn up as well as convulsed; his 
speech also seemed affected. Shortly afterward, this was succeeded 
by another fit of the same character, which commenced with a feel- 
ing of pins and needles in the right shoulder, extending to the arm 
and hand. From the Saturday to the Sunday evening inclusive he 
had ten such attacks. On the Monday he had an epileptic fit, which 



NEURALGIA. 741 

lasted two hours, soon afterward followed by another, which did not 
last so long. 

"Wednesday. — The child has had no more epileptic fits; but the 
lesser seizures still continue, occurring very frequently. He appears 
much alarmed at them. His mouth and cheek are drawn up during 
a fit, and he cannot speak; but says, 'Mother, it is going,' as the 
attack is leaving him. On this day Mr. Coleman extracted his four 
temporary second molar teeth, all of which were decayed, but had 
given him little or no pain. 

"May, 1861. — Has remained perfectly free from the before-men- 
tioned seizures since the removal of the teeth until within the last 
two days, during which he has had seven slight attacks. One of 
the first temporary teeth was found to be carious, and it was removed 
about a week after this. His mother called and stated that he had 
one very slight attack since the removal of the tooth ; she promised 
to bring him should a second occur, but neither mother nor child 
has been seen since that time. 

" Case II. — M. J., aged about twenty-three years ; is healthy-look- 
ing, and enjoys very good health; suffers much from toothache, and 
during the fits has a tingling sensation in the palms of his hands 
and soles of his feet, but especially in the left arm. Several of his 
teeth were decayed, but not so much so as to require removal ; they 
were filled with gold, since which he has had no return of pain or 
the accompanying sensations." 

"Amaurosis consequent on Acute 'Abscess' of the Antrum, pro- 
duced by a Carious Tooth. — By S. J. A. Salter, M.B., F.L.S. Read 
before the Royal Medical and Chirurgical Society. — The case upon 
which this paper was based was one of unusual severity, and of 
exceptional complications. The patient, a young woman twenty- 
four years of age, was attacked with violent toothache in the right 
upper first molar, which was followed by enormous swelling of the 
side of the face, and intense pain. The eyeball then became pro- 
truded, and she soon after perceived that the eye was blind. Shortly 
after the establishment of these symptoms, ' abscess' of the antrum 
pointed at the inner and then at the outer canthus, and a large dis- 
charge of pus at both orifices followed ; these orifices soon closed, 
and the general symptoms of the part continued unchanged, — the 
swelling of the face, protrusion of the globe, and blindness. This 
state of things lasted for about three weeks, when the patient was 
sent to Guy's Hospital, and admitted. 

"At this time the patient exhibited hideous disfigurement from 



742 ORAL DISEASES AND SURGERY. 

swelling of the face, oedema of the lids, and lividity of the surround- 
ing integument. Upon examining the mouth, it was found that the 
carious remains of the first upper right molar appeared to be asso- 
ciated with and to have caused the disease. Together with the 
other contiguous carious teeth, this was removed, and led, by an ab- 
sorbed opening, through the floor of the antrum. The hemorrhage 
which followed the operation was discharged partly through the 
nose and partly through the orifices in the cheek, as well as from 
the tooth-socket, showing a common association of these openings 
with the antrum. The condition of the eye constituted the most 
important symptom, and the most distressing. The sight was 
utterly gone ; the globe prominent and everted. There was general 
deep-seated inflammation of the fibrous textures of the eye. The 
pupil was large and rigidly fixed ; it did not move co-ordinately with 
the other under any circumstances. Some abatement of the symp- 
toms followed the extraction of the tooth ; but it was soon found that 
there was a considerable sequestrum of dead bone, which was re- 
moved. The necrosis involved the front part of the floor of the 
orbit, the upper cheek portion of the superior maxijla, with the infra- 
orbital foramen, and a large plate of bone from the inner (nasal) 
wall of the antrum. The removal of the dead bone was followed 
by the immediate and complete cessation of all inflammatory symp- 
toms ; but the eye remained sightless, and the pupil rigidly fixed. 
About five weeks after the removal of the dead bone, it was noticed 
that the pupil of the affected eye moved with that of the other, 
under the influence of light, though vision in it had not returned. 
The eye was frequently examined at this stage with the ophthalmo- 
scope. All the structures, including the retina, appeared healthy, 
except the termination of the optic nerve, which was perfectly 
white and anaemic, while that of the other eye was pink and 
natural. 

" The author referred to two other cases essentially similar to his 
own. The first (unpublished) occurred in the practice of Mr. Pol- 
lock, of St. George's Hospital. The patient had intense inflamma- 
tion of the entire maxillary region on one side, caused by a carious 
tooth. It implicated the whole face and the contents of the orbit, 
but was not attended by 'abscess' of the antrum or necrosis of bone. 
The inflammation completely ceased on the removal of the tooth, 
but the sight was permanently lost ; the pupil was at first fixed, but 
afterward moved with that of the other eye. 

"Another example, closely resembling these, was published by 



NEUBALGIA. 743 

Dr. Briick, in Casper's ' Wochenschrift' for 1851. It was, however, 
more chronic, and the loss of vision was only temporary. 

"The author concluded his paper by suggesting that the serious 
ophthalmic symptoms depended on the nerves of the eye being in- 
volved in a plastic inflammation in their course, external to the skull 
and before their distribution ; that the optic nerve was permanently 
damaged, as shown by the permanent blindness; and that the third 
nerve was temporarily implicated, as shown by the temporary fixed- 
ness of the pupil ; and the eversion of the eye from the first seemed 
to indicate that the sixth nerve was less or not at all involved. 
Finally, the author left it an open question whether the ansemia of 
the optic nerve, as displayed by the ophthalmoscope, is to be 
looked upon as a cause or consequence of its suspended function." — 
{Lancet.) 

Sympathetic Action. — In the course of an article on " Amaurosis 
and other Disorders of the Eye, resulting from Injury of the Terminal 
Branches of the Fifth Pair of Nerves," in the American Journal of 
the Medical Sciences for July, Dr. D. Lente gives the following 
interesting observations upon the sympathetic relations of the teeth 
and eye : " Middlemore says ' amaurosis may arise during the period 
of dentition ; it may take place from the irritation of a carious tooth ; 
from laceration or other injury of the supraorbital nerve.' He relates 
a case in which Mr. Howship removed an encysted tumor from the 
scalp, which produced ' marked and permanent improvement in 
vision.'' Another case, in which M. Demours removed a tumor from 
the neighborhood of the eye, and thus produced amaurosis. Another 
from the Edinburgh Medical and Surgical Journal, ' which would 
appear,' he says, ' to prove that wounds of the infraorbital nerve 
may restore the sight of an eye which has long been lost from an 
amaurotic affection.' ' A man was affected with perfect gutta serena 
of the right eye, and had the sight of the eye restored, he thinks, 
in consequence of receiving a smart blow in the neighborhood of the 
infraorbital nerve of the right side of the face.' Another still more 
striking case, in which a person received 'a wound just above the 
right eyebrow from a piece of glass, which was removed imme- 
diately after the accident.' When the wound had healed, ' the sight 
of the right eye was very nearly lost ; he has had a painful sensation 
in the neighborhood of the cicatrix, and a singular sense of creeping, 
and pinching and quivering of the upper eyelid and the integuments 
of forehead.' ' I made a free incision of the cicatrix down to the bone, 
and all uneasiness at once ceased, and the eye, shortly after, assumed 



744 ORAL DISEASES AND SURGERY. 

its healthy character and functions, and vision was permanently 
restored.' Lawrence, after relating two or three cases of amaurosis 
following wounds and the formation of cicatrices over the brows, 
remarks, ' It is still a matter of doubt whether injury of the frontal 
nerve may cause amaurosis.' And yet, he adds, 'injury or other 
irritation of the trigeminus may bring on impaired vision or amau- 
rosis.' ' The sympathy between the trigeminus and the immediate 
nervous apparatus of vision affords the only explanation of some 
apparently obscure cases, in which amaurosis seems to have de- 
pended on a carious tooth, or on some other local affection seated 
in the head.' 

" The following remarks by Marshall Hall were reported in the 
London Lancet: 'These experiments,' alluding to those made by 
Magendie, 'are not the only evidence we possess of the influence 
of the fifth pair on vision.' 'In an interesting case under my 
own care, a partial amaurosis of the right eye has arisen appar- 
ently from the caries of the upper canine tooth of the right side.' 
It was augmented by unsuccessful efforts at extraction. It has not 
ceased, however, since extraction was effected. ' These facts,' says 
he, speaking of this and other cases, ' with the similar results from 
wounds or tumors of the supraorbital branch of the fifth, appear to 
me to confirm the extraordinary experiments of Magendie.' Hennen 
says, ' I have met with one or two cases of amaurosis from wounds 
of the supraorbital nerve.' ' Scarpa,' he says, ' doubts of the pos- 
sibility of the cure of amaurosis from this cause, and mentions Val- 
salva's case as the only one on record.' Mr. Hey, however, states 
another in the Medical Observations and Inquiries, vol. v. M. 
Larrey mentions another. Yicq d'Azyr, who gives a case of amau- 
rosis from a wound of this nerve, in the Histoire de la Societe 
Royale de Medecine, annee 1176, says he has 'since divided this 
nerve in quadrupeds, but without producing any such effect.' 

" That defective vision may result as the direct consequence of 
irritation of the terminal branches of the fifth pair may also be in- 
ferred from the effects of remedial applications to these nerves, and 
from the phenomena observed to follow irritations and injuries of 
other branches not so immediately connected with the eye. Some 
of these instances it will be proper to mention. A friend of the 
writer, a distinguished surgeon of New York City, was incapaci- 
tated for business by violent neuralgia of the face ; after having 
suffered some time with it, he noticed that one of his molar teeth 
was defective, and went to a dentist to have it examined, — not 



NEURALGIA. 745 

supposing, however, that it had any connection with his neuralgia, 
since it gave him no pain. Its removal was advised. The operation 
was scarcely over before the doctor experienced complete relief 
from his excessive pain. ' I felt,' he said, 'as if I could have 
shouted for joy.' A lady, a short time since, applied to me to 
extract a tooth for her little daughter, which, she said, had been 
causing her excruciating pain day and night ; but, on examination, 
I could discover no defect, and prescribed some anodyne remedy, 
which gave only temporary relief. A dentist was called in, who 
also declined extracting a sound tooth, but on a second visit, and a 
closer examination, detected an unsound tooth at some distance 
from the offending one, and extracted it. The pain instantly ceased, 
and did not recur. Mackenzie relates a remarkable case in point. 
A man had violent neuralgia of the eye, soon succeeded by amau- 
rosis, and continuing, notwithstanding various treatment, from the 
autumn of 1825 until the beginning of 1827. At this time M. 
Galenzowski, to whom he applied, 'found vision of the left eye lost 
and the pupil dilated. He extracted a decayed tooth from the left 
upper jaw, and, to his astonishment and that of the patient, found, 
attached to its root, a splinter of wood, supposed to have been origi- 
nally attached to a toothpick of wood. Nine days after, the patient 
had entirely regained his sight.' Mackenzie relates another equally 
remarkable case, occurring in the practice of Dr. Van Zandt, of St. 
Louis, ' of a young man affected with complete amaurosis, excited 
by the persistence of two deciduous teeth. As soon as they were 
extracted, the patient looked up as if terrified, and found his vision 
restored.' 'Morgagni, Notta, Deval, Tavignot, and others,' says 
M. Echeverria, 'have known amaurosis to be caused by neuralgia, 
and to disappear as soon as the neuralgia was cured.' (The italics 
in the above references are my own. — L.) Such cases as these 
might be multiplied, but it is scarcely necessary." * * * 

" There are several features in the rather remarkable history of 
Antoinette H. which require some notice before concluding this 
article. It was objected by a very distinguished oculist, to whom 
the case " [one in which part of a gun cap was accidentally driven 
into the pericranium of the left side of the forehead, producing 
amaurotic and other disturbance] " was related, soon after its occur- 
rence, that, the wound being on the left side, the amaurotic symp- 
toms should have affected the left eye, and not the right. But this 
is not more remarkable than that disease in one tooth should occa- 
sion a violent toothache in another perfectly sound ; or that irritation 



746 ORAL DISEASES AND SURGERY. 

of the nerves of the stomach by acidity should induce violent neu- 
ralgia of the supraorbital nerve ; or that an irritating application to 
the mucous surface of the eyelid should determine also an immediate 
irritation of the Schneiderian membrane, succeeded by violent sneez- 
ing ; or that simply touching the membrana tympani with a probe 
should sometimes give immediate relief to a toothache." — {Dental 
Cosmos.) 

" Facial Paralysis. — Dr. Coale reports the following case. The 
patient was a healthy, well-regulated girl, aged eighteen, who at first 
noticed that her face was somewhat stiff, and in twenty-four hours 
completely paralyzed on the left side. There was great distortion 
on laughing or talking, a staring left eye, and tenderness of the 
whole left side of the face. The tongue was not at all affected, the 
disease being confined to the portio dura. No cause could be found 
for it, unless it were that she had defective teeth in each jaw, as 
much, however, on one side of the mouth as the other. The treat- 
ment consisted of leeches to the place of exit of the nerves, strychnia, 
etc., but with no benefit. After the lapse of three weeks, she was 
advised to have her carious teeth removed, and thirteen were accord- 
ingly extracted. This was followed by manifest improvement in 
the course of five days. Electro-galvanism was then gently em- 
ployed, and the patient recovered. 

" Dr. Tyler said that several years ago he had under his care a 
lady with severe sciatica, for which all the usual remedies had been 
tried in vain. Finding that she had several -decayed teeth, he ex- 
tracted four or five of them, with benefit. The remainder were sub- 
sequently drawn, after which the patient had no more pain. 

"In 1853, a boy, aged nineteen, was brought to the New Hamp- 
shire Asylum in a state of mania. Dr. Tyler ascertained that he 
had had a tooth extracted some time previous, and that one of the 
fangs had broken off, and remained in the jaw. Suppuration took 
place, the pus discharging outwardly, and the boy was suddenly 
attacked with mania. The fang was removed. The fistulous opening 
closed, and the patient quickly recovered from his mania. 

" In another case of mania, the patient being a young lady, several 
decayed teeth were removed. The patient remained to some extent 
under the influence of the ether, which was given at the operation, 
for twenty-four hours. After that she was cured of the mania." 

Insanity sometimes caused by Diseased Teeth. — James Trudeau, 
M.D., of Paris, says, "M. Esquirol told me that he had cured a 
young lady, who was insane, of her mania by the extraction of her 



NEURALGIA. 747 

second molar tooth, which was preventing the growth of a wisdom- 
tooth." 

Epilepsy from Diseased Teeth. — Dr. Rush ("Medical Inquiries 
and Observations") says, "Some time in the year 1801, I was con- 
sulted by the father of a young gentleman in Baltimore, who had 
been afflicted with epilepsy. I inquired into the state of his teeth, 
and was informed that several of them in his upper jaw were much 
decayed. I directed them to be extracted, and advised him after- 
ward to lose a few ounces of blood at any time that he felt the 
premonitory symptoms of a recurrence of his fits. He followed my 
advice, in consequence of which I had lately the pleasure of hearing, 
from his brother, that he was perfectly cured." 

Paralysis from Dental Irritation. — The American Journal of 
Dental Science, New Series, vol. i. p. 504, quotes from the London 
Lancet, as reported by J. L. Levison, of Brighton, the following 

case: "Miss , a young lady, was brought in a carriage to my 

residence to have her mouth examined. On being removed, she 
was supported by a lady on one side and a man-servant on the other, 
and her entire muscular system seemed paralyzed. Her legs trailed 
on the ground like useless appendages ; her arms, when raised, fell 
powerless immediately, when unsupported ; and even the muscles 
of the tongue were paralyzed, and in her efforts to speak, this im- 
portant organ remained in a quiescent state. On examining the 
mouth, I perceived a dens sapientiae of the lower jaw very carious, 
and deeply imbedded in the temporal muscle, just below the ridge 
of the coronoid process, in which locality there was extensive in- 
flammation. I suggested the removal of the tooth ; and, though I 
had anticipated some advantage from the operation, the actual result 
astonished me. She instantly obtained the free use of her tongue, 
which she immediately used to communicate an important fact, viz., 
that ever since the tooth I had extracted had been making its way 
through the gum she could date the gradual loss of power over her 
limbs, etc. I saw her about a month afterward; she could then use 
her hand and arm, — she was writing a letter ! Since then I have 
not heard what progress she has made." 

Sir Astley Cooper, in speaking of the effects of slight irritation, 
says, " M. Toulmin, of Hackney, attended a lady on account of her 
suffering unusually from a diseased tooth, and she appeared to be 
afflicted with hemiplegia. M. Toulmin extracted the tooth, and in a 
short time the paralytic affection entirely subsided." 

Catalepsy from Toothache. — The Dental Recorder, vol. viii. No. 



748 ORAL DISEASES AND SURGERY. 

1, p. 197 (1854), quotes from The Stethoscope, as reported by Dr. 
Huton, the following case : 

" Willis, a plowboy (October last), was complaining of toothache 
early in the morning; half an hour after commencing work was 
observed lying a short distance from the plow, apparently dead. He 
was carried to the house, nearly a mile, and the doctor (five miles 
distant) sent for. In the belief that the effect might be produced 
through the dental nerve, the tooth was extracted, when the boy 
immediately got up and expressed himself as well as ever; and has 
continued well since. He had been an unusually healthy boy, and 
had never had a physician to see him before." 

The following interesting and, in a neuralgic aspect, suggestive 
cases were collated by Dr. Abraham Robertson,, of Virginia, and 
published in the Dental Cosmos : 

11 Chorea is sometimes caused by Dental Irritation. — The Ameri- 
can Journal of Dental Science, vol. vi., New Series, p. 146, quotes 
from the Dental News Letter the following 

" Case. — Dr. Billard says, after an examination of the case, which 
was one of what is commonly called St. Vitus's dance, that he found 
several stumps in both jaws, the gums entirely covering some of 
them, and on pressure of the same it caused her great pain, and 
pus exuded on the slightest pressure. *****! proceeded 
to give ether, and it took a double quantity to make her insensible 
to pain. I then took out eight stumps and some small pieces of 
dead alveoli, which had caused a continuous irritation of the parts. 
Since that time, the author states, the paroxysms grew less frequent, 
and now the patient, Miss L., enjoys her usual health." 

" Erysipelas from a Diseased Tooth ; Death of Patient. — The 
following case was reported by Dr. Thompson, of the 'Seaman's 
Retreat' (N. Y.), and furnished to the New York Medical Gazette, 
in which it was published, vol. iii. p. 263 (1852), by Dr. Sayer, of 
that city. 

" Case. — Charles Lunt, aged thirty, Swede, arrived June 28 from 
Havre. Admitted into hospital, at the date just mentioned, for an 
inflammatory tumefaction of left cheek and parotid gland of three 
days' standing, as patient stated, from toothache, with which he had 
been annoyed for several days previous to the swollen face. Patient 
otherwise healthy, and of a stout, robust appearance. 

"On admission, the tooth of which he complained was extracted ; 
there discharged, in cutting about the tooth, a considerable quantity 
of fetid pus. After extraction of the tooth, a powder of calomel 



NEURALGIA. 749 

and rhubarb was given, and an emollient poultice applied to the face. 
The latter was continued, and antiphlogistic remedies pursued, but 
without much relief to the pain or reduction of the swelling, — when, 
after several days, the inflammation assumed an erysipelatous char- 
acter. The affected parts were now painted with a strong solution 
of nitrate of silver, evaporating lotions applied, and the remedies 
indicated .by the constitutional symptoms administered internally. 
This treatment persisted in, the inflammation, in a short time, greatly 
subsided, and these promised hopes of a speedy recovery. Suddenly, 
however, the erysipelas commenced to spread, and the accompany- 
ing symptoms to increase in violence, until the palpebra of the (left) 
eye and parts adjacent became involved. As the disease advanced, 
pus was formed in several places, which was evacuated. The con- 
junctiva, partaking of the contiguous inflammation, became swollen 
and oedematous. The other tissues of the eye also soon became 
involved, and now occurred delirium and other symptoms indicative 
of the extension of the inflammation to the brain. This being ap- 
prehended, a vigorous revulsive antiphlogistic course of treatment 
was adopted, but without much relief to the patient. The symp- 
toms just alluded to continuing, and gradually increasing in violence, 
the disease on the fourth day of their occurrence proved fatal." 

"Vicarious Menstruation from Decayed Teeth. — Dr. Rush, 
'Medical Observations and Inquiries,' says, in the second number 
of a work entitled ' Bibliotheque Germanique Medico-Chirurgicale,' 
published in Paris by Dr. Bluver and Dr. Delaroche, there is an 
account published by Dr. Siebold of a young woman who had been 
affected for several months with great inflammation, pain, and ulcers 
in her right upper and lower jaws, at the usual time of the appear- 
ance of the catamenia, which at that period were always deficient 
in quantity. Upon inspecting the seats of these morbid affections 
the doctor discovered several of the molars in both jaws to be de- 
cayed. He directed them to be drawn, in consequence of which 
the woman was relieved of the monthly disease in her mouth, and 
afterward had a regular discharge of her catamenia." 

" Dr. S. P. Hullihen reported the following 

" Case. — A young lady, about seventeen years of age, applied 
with a fungous growth in each of the second molars of the lower 
jaw, which had assumed rather a novel character. She stated that 
the fungi had made their appearance in both teeth at the same time, 
about four years before, and that for the last two years she had 
been much troubled with a bleeding from them, which took place 



750 ORAL DISEASES AXD SURGERY. 

regularly once a month, and continued several days. She being 
very anxious to have the teeth saved, I destroyed, to all appear- 
ance, the morbid growth, and plugged the teeth. In a few davs 
they became sore and painful. The plugs were removed, and a slight 
bleeding commenced, which continued three or four days, and then 
the tumors entirely disappeared. I was. therefore, induced to plug 
them again; but in about three weeks the teeth became sore: the 
plugs were removed, and a bleeding ensued as before. I now sus- 
pected it to be a vicarious menstruation, and mentioned the case to 
the family physician. At his request I plugged them again, and the 
result was precisely as before. The teeth were then removed, and 
the patient was put under a course of treatment by her physician, 
which effected a cure. 

"As somewhat allied to this. I will here venture the opinion, 
although I have no case in mind by which to illustrate the fact, that 
other uterine diseases are often greatly aggravated, if not induced, 
by this same cause. And, improbable as it may at first seem, 
especially do I believe this to be true in relation to one of the most 
common afflictions — a very severe affliction, too — of the females of 
our country, prolapsus of the uterus. 

"This much, at least, is certain: general debility, however in- 
duced, is a most common cause of this complaint ; and I have often 
observed that when it is not complicated with other diseases, as in- 
flammation, ulceration, etc.. it may readily be cured, often by topical 
applications only, or by topical applications in conjunction with 
tonics and healthful exercise in the open air, and sometimes by the 
tonics and exercise without any topical treatment, or perhaps by 
Dr. Meigs's cure alone, of ' six miles' walk a day, commencing with 
small doses, and increasing according to ability ;' but if from any 
cause the general health afterward suffers, and debility ensues, a 
recurrence of the prolapsus will also be likely to ensue. And since 
diseased teeth, by the nervous irritation they produce, by the de- 
rangement they cause in the digestive and respiratory organs, are 
a most common and potent cause of such debility, they must neces- 
sarily be the cause, indirectly at least, of this kind of suffering.'' 

Epilepsy connected with Dental Irritation. — " I. D., aged thirteen, 
has had epilepsy eighteen months. Had no tits in infancy, no ner- 
vous affection up to the period of present illness. Family history 
good. First attack occurred after eating some crab-fish for supper. 
It was long and violent. The second occurred after two months' 
interval ; cause of this not known. The third occurred in fourteen 



NEURALGIA. 751 

days, and they have recurred at varying intervals, — from one week 
to three weeks. They always occur during the night. He screams 
sometimes, and not unfrequently bites his tongue. Latterly his 
mother has noticed that some days he rubs his left cheek, complain- 
ing of face-ache, after which the fit follows. He is a healthy-looking 
boy ; tolerably well-fleshed, although the muscles feel somewhat 
flabby. He is intelligent, and does not appear to have suffered in 
apprehension or memory ; no headache or vertigo. Organic func- 
tions tolerably well performed ; no inter-paroxysmal phenomena. 
On examining the mouth, there is to be seen a molar tooth consider- 
ably decayed, with a swollen gum around it, and partly growing 
over into the cavity ; it is not very tender to touch, and the exami- 
nation does not give rise to toothache. On questioning, I find the 
sensation which the boy experiences before a fit does not seem to be 
one of pain, but rather of an indefinite uneasiness. He always has 
a fit the night on which this uneasiness comes on. Has never felt 
it during the day; it is always about seven to eight o'clock. I 
desired the mother to have the tooth extracted, and ordered a simple 
saline, with a quarter of a grain of belladonna, to be taken twice 
daily. This was in June. The tooth was extracted next day. I 
saw this boy once a fortnight from that time for four months, but 
he has had no recurrence of the fit. 

"In this case I believe an unfelt aura commenced about the gum 
surrounding the tooth, and was not recognized till some degree of 
inflammation arose, and thus a modification of pain became asso- 
ciated with the aura, and directed attention to it. I have, at the 
present moment, another and very similar case to this. The extrac- 
tion of the tooth has not yet been performed, so that I cannot give 
you the result. When epilepsy occurs in children, I always examine 
the mouth, with the twofold view of observing the vault as to height, 
narrowness, etc., inasmuch as no observation about the cranial de- 
velopment can be complete without such examination, and of ascer- 
taining whether any cause of eccentric irritation may spring from 
decayed or crowded teeth. I would observe here that, later, the 
dentes sapientise often become a source of considerable irritation, 
and, therefore, of complication, at least in the epilepsy of young 
persons." — (Dr. J. S. Ramskill, Medical Times arid Gazette.) 

Many very interesting and instructive cases of neuralgia may be 
found by the reader reported by Dr. S. Weir Mitchell in his work 
on "Injuries of the Nerves," which can only be studied with the 
result of adding indorsement to the inference of the local origin of 
this complaint. 



752 ORAL DISEASES AND SURGERY. 

Among the reports of the clinical services of the author will be 
found two by Dr. De Forrest Willard, where in one instance an old 
man who had suffered with neuralgia of the head for sixty years, 
and who many years back had endured section of the facial nerve, 
was cured by the removal of an imbedded tooth-fang conjoined 
with the extraction of an abraded inferior incisor. In the second 
case, a German aged about fifty, a neuralgia which had been under 
every variety of treatment for several years was clearly demon- 
strated to depend on calcification of dental pulps. 

The use of the constant galvanic current is credited with the cure 
of many cases of neuralgia, — the Weiss battery, used with from 
ten to fifteen cells, being, in this direction, highly commended by Drs. 
Anstie, Buzzard, Joseph Stead, and others. The Stohrer battery, 
made by the Galvano-Faradic Company, of New York, is highly 
spoken of by Dr. S. Weir Mitchell. 

Batteries made in Philadelphia are quite equal to any others, 
either of foreign or domestic make. In sixteen cases of treatment 
by battery application, Dr. Buzzard reports "ten followed by very 
great and well-marked relief, two by moderate relief, and four by 
very slight relief." 

" Dr. Anstie refers to two cases, — one of severe neuralgia in the 
right cervico-brachialis, in a married woman aged forty-eight ; the 
other of a double cervico-occipital neuralgia, in an unmarried 
needle-woman aged thirty. In the former case a cure was effected ; 
in the latter, not. The constant current was employed, with the 
strength of ten cells, afterward increased to fifteen ; the positive 
pole in the first case being applied alternately on the various foci 
of pain, the negative pole being applied by the right side of the 
three lower cervical vertebrae. The pain was at once diminished, 
and ceased altogether at the end of thirteen days ; and a secondary 
anaesthesia of the skin, with secondary paralysis of the deltoid and 
trapezius, was removed at the end of twenty-four days' treatment. 
The cure was found persistent six weeks later. Dr. Anstie re- 
marks that the effect of the constant current in neuralgia is re- 
markable, but that there are as yet some unexplained anomalies 
in its action. In the large majority of cases it acts as a palliative 
most strikingly. In a not inconsiderable number of cases it ap- 
pears to cure the disease absolutely; in a few examples it fails 
to produce any good effects. As a general rule, it is far less 
effective in the neuralgias of old persons with degenerated tissues 
than in younger subjects ; but occasionally even a young person, 



NEURALGIA. 753 

like the second of his cases, fails to derive benefit from it." — {Lancet 
and New Remedies.) 

A writer in The American Practitioner recommends dropping 
into the meatus auditorius from four to ten drops of the following 
mixture, remarking it to be " very rare, with the use of this liquid, 
that relief is not obtained in a few minutes, and the patient asleep 
in half an hour, whatever may have been the severity of the pains, 
and that without having been in the least danger. Absorption 
takes place almost as rapidly as from a denuded surface, and it is, 
therefore, unnecessary to blister the patient when we wish to use 
narcotics, since they act almost as rapidly by the auditory passage. 

R. — Extracti opii, 

Extracti belladonna?, 
Extracti stramonii, aa pars j ; 
Aquae pruni Yirginiani, partes xij. 

" If it should happen," says this writer, " that at the end of eight 
or ten minutes the pain does not yield to the remedy (which some- 
times happens when the quantity used has been too small, or when 
we have to treat a neuralgia which has already required the use of 
narcotics in any way), it is necessary to use a second dose, at least 
equal to the first, but in the opposite case, in order to obtain 
promptly that relief which is only too frequently momentary, of 
facial neuralgias of long standing." 

Alluding to the extemporaneous character of the preparation, it 
is suggested that it may be preserved, if care is taken to keep it cool, 
by pouring on its surface from two to four drops of sweet almond 
oil. 

Among the recipes found in Dr. Napheys's "Modern Therapeu- 
tics," which have been selected from the most eminent practitioners, 
are the following, which may not be without service to many readers : 

Wm. Aitken, M.D., Edinburgh : 

When the neuralgia is superficial, compresses steeped in the fol- 
lowing solution : 

R. — Atropiae sulphatis, gr. v ; 
Aquae destillatae, f^iij. 

Renew the compresses several times in twenty-four hours, con- 
tinue them for at least an hour each time, and cover them with oil- 
skin to prevent evaporation. 

48 



754 ORAL DISEASES AND SURGERY. 

Brown-Sequard : 

R. — Extracti belladonnas, gr. 1 ; 

Extracti stramonii, gr. -J- ; 

Extracti cannabis Indicae, gr. -J ; 

Extracti aconiti, gr. ± ; 

Extracti hyoscyami, gr. | ; 

Extracti conii, gr. j ; 

Pulveris glycyrrhizas, q. s. 
For one pill. To be used with care, and not over four a day. 

Dr. Da Costa : 

R. — Aconitiae, gr. ij ; 
Yeratriae, gr. xv ; 
Glyceriuae, f3ij ; 
Cerati adipis, 3vj. M. 
To be rubbed over the painful part, care being taken to see that 
there is no abrasion of the skin. 

Dr. Wm. Hammond : 

R. — Extracti belladonnas, gr. v. 
Divide into twenty pills. One three times a day. 

Liniment of Guy's Hospital : 

R. — Liquoris plumbi subacctatis, 

Tincturae opii, 

Mellis, aa 5'j 5 

Confectionis rosae, 3j. 
Fiat linimentum. 

London Hospital : 

R. — Tincturae aconiti, 

Linimenti saponis, aa fjj. 
To be used as an anodyne liniment. 

A liniment recommended by Dr. Napheys as an elegant sedative 
is as follows : 

R. — Atropiae sulphatis, gr. viij ; 
Morphias sulphatis, gr. xvj ; 
Aconitiae, gr. ij ; 
Acidi sulphurici diluti, *lv ; 
Alcoholis, f^ss ; 
Olei olivae, q. s. ad f^iv. M. 



\ 



NEURALGIA. 755 

Or, if a stimulant effect is also desired : 
R. — Chloroformi, f^ss ; 

Spiritus terebinthinge, f^j ; 
Camphoris, 5j ; 
Olei lavandulaa, "Ixx ; 
Olei olivaa, q. s. ad f^yj. M. 
The first four ingredients should be mixed before adding the oil, 
and the liniment should be well shaken before it is applied. 

Dr. Felix von Niemeyer, University of Tubingen : 
R. — Extracti hyoscyami, 
Zinci oxidi, aa 9ij. M. 
Divide into eleven pills. Begin with one pill morning and even- 
ing, and increase to twenty or thirty of them daily. These, known 
as the Meglin pills, have a good reputation in Germany. 

Edward Wakes, M.D., London : 

R. — Potasses bicarbonatis, 3ss ; 

Extracti ergotse fluidi, f3j ; 

Infusi ergotse, f^vj. M. 
Two tablespoonfuls every four hours in tic-douloureux. 

One of the most intractable neuralgias of the head ever met with 
in the practice of the author, yielded to compression of the facial 
arteries. 

Methodical rubbing of a neuralgic seat is recommended by Dr. S. 
Weir Mitchell. 

In a case, noted by this author, of contusion of the ulnar nerve 
subject to intense neuralgia, the nerve being hardened and enlarged, 
tender, and enduring no application of electricity, the pain was re- 
lieved by hypodermic injections ; but after using many remedies, 
and at last the actual cautery over the nerve-trunk without altering 
its size or tenderness, slow and careful manipulation was tried to 
test if it could be enabled to bear pressure. After a course of gentle 
friction, lasting half an hour, the object was attained, three sittings 
enabling the parts to be rubbed and even kneaded quite roughly. 

Concerning the odonto-neuralgias, the reader is referred to the 
chapter on Odontalgia. 



CHAPTER XXXYII. 

THE TONGUE AND ITS DISEASES. 

Of medical diseases the tongue has long been esteemed a reliable 
sentinel : hence, many and varied must be its expressions of functional 
derangements in the system at large. To term such expressions 
disease, however, could not by any means be proper, the sympathetic 
relationship being evident to the most superficial observer. In the 
foot-note the reader will find such medical aspect of the subject con- 
sidered with all fullness.* 

* " In drawing inferences from the condition of this organ, it is important 
to know whether the appearances it may present are the result of local disease 
in the mouth, or of the sympathies which connect it with other parts of the 
system. In general, there is little difficulty in coming to a correct conclusion 
upon this point: it is only necessary that the 'attention should he directed 
toward it. This organ seems to have been designed as an index, to the eye as 
well as to the ear, of the state of the system, so numerous and diversified are 
the morbid affections which modify its healthy appearance. It not only par- 
ticipates in all general derangements of the whole system, serving as one of 
the surest guides to a correct judgment in relation to the degree, progress, 
and precise stage of the disease, but especially also sympathizes with the 
different parts of the digestive tube, at one extremity of which it is placed. 

" The bulk of the tongue may be increased or diminished. Its enlargement, 
when not so considerable as to be yevy obvious, may often be known by the 
appearance of indentations on its sides, made by the pressure of the teeth. 
This is occasionally one of the first signs of the mercurial influence. Its 
contraction, when not the mere effect of dryness, is usually the result of a 
diminished supply of blood, and indicates either a general deficiency of the 
circulating fluid, or great feebleness of the heart's action. Like every other 
part naturally moist, it shrinks by drying ; and, under such circumstances, 
no general inference can be deduced from its mere loss of volume. 

" Its color is often greatly and significantly modified. Morbid floridness of 
the tongue is the consequence either of the condition of the blood, or of its 
greater abundance in the organ. In the former case an unduly arterialized 
state of the mass of the blood is indicated ; in the latter, either over-excite- 
ment of the circulation generally, or phlogosis of the stomach. Eedness of 
the tongue, no.t the result of local causes exclusively, has been supposed by 
some pathologists to be an almost certain sign of gastric inflammation or 
irritation. But this is far from being the case. It is often seen when no 
(756) 



THE TONGUE AND ITS DISEASES. 757 

Of organic or surgical diseases the tongue seems to have its full 
share. These diseases are of a twofold relation : local, as reference 



evidence of gastritis is presented, either by the symptoms or upon dissection, 
and is not unfrequently absent when that disease exists. Serious practical 
injury may result from this error. The red tongue can be considered as 
having special reference to the stomach only when other symptoms point in 
the same direction, and even then is by no means a certain sign. A livid or 
purple color of the tongue is usually dependent upon an insufficient aeration 
of the blood, and is a valuable sign in connection with the same color of the 
lips. Not unfrequently the tongue is morbidly pale; and this state is a sign 
of deficiency of the blood in general, or of its red corpuscles in particular, or 
of great prostration of the circulating forces. 

" Its condition as to dryness and moisture is often highly significant. But 
caution is necessary not to mistake dryness from temporary and unimportant 
causes, for that which results from general disease. In persons who sleep 
habitually with their mouths open, the tongue is apt to be dry in the morning ; 
and the same cause often produces the same effect in sickness. On visiting a 
patient we find the tongue unexpectedly dry, and begin to feel some appre- 
hension, until we learn that the patient has been breathing for some time 
through the mouth alone. A stoppage of the nostrils often gives rise to this 
phenomenon. In all doubtful cases it is only necessary to request the patient 
to close his mouth and then move the tongue about so as to moisten it. If 
he succeed satisfactorily, we may conclude that the dryness was accidental, 
and of no account. Another caution is requisite : to take care, namely, that 
a really dry tongue should not be mistaken for a moist one, in consequence 
of the patient having recently taken a liquid into his mouth. Dryness may 
exist in different degrees, from mere clamminess to perfect aridity. It de- 
pends on a deficiency of saliva, or of mucus, or both, and indicates a general 
tendency to diminished secretion. It not unfrequently occurs, as a sympa- 
thetic affection, in ulcerative inflammation of the small intestine. It affords 
sometimes. the most important therapeutical indications. 

" The temperature of the tongue serves as a guide to that of the body gen- 
erally. When cold, it evinces, for the most part, great prostration of the 
powers of life. It proves that the process of calorification is failing at the 
very fountain ; for the breath must be cool before the tongue can become so 
in any considerable degree. This coldness of the tongue has been frequently 
noticed in severe cases of epidemic cholera. But we must take care not to 
confound coolness from local causes, as from ice in the mouth, or from the 
patient having slept long with the mouth open in a cold atmosphere, with 
that proceeding from the state of the system. Heat of the tongue, except 
when arising from inflammation of the organ, may be considered as a sign of 
a general elevation of temperature. 

" But the condition usually denominated a furred tongue is, perhaps, the 
most valuable diagnostic symptom afforded by that very important little 
member. In this state the tongue is covered with a morbid coating, which 
adheres so firmly that it cannot be removed without removing a portion of 



758 ORAL DISEASES AND SURGERY. 

is had to some direct cause demanding only local attention ; indirect, 
as constitutional offense is the agent against which a treatment is 
to be directed. 

the surface along with it. Occasionally deposits take place from the saliva 
and the mucus of the mouth; but these are easily removable, and must be 
distinguished from the genuine fur. The latter proceeds from a secretory 
process of the tongue itself, and seems to be incorporated with the superficial 
layer of epithelium. It is almost always confined to the upper surface, where 
the structure of the membrane is papillary. Though very generally a sign 
of disease, it is not always so. Some persons have a furred tongue habitually, 
more especially upon rising in the morning ; and, though in the greater 
number of these there is probably some chronic disorder of digestion, yet in 
others the health appears to be perfect. 

" A furred tongue almost always accompanies fever, and is one of the most 
decided characteristics of that affection. Indeed, when considerable in degree, 
and not dependent upon stomatitis of any kind, it may very generally be re- 
garded as a febrile symptom. When the fur is white, thickish, tolerably uni- 
form, and accompanied with moisture, it usually indicates an open, active 
state of fever, in which, though the obvious symptoms may possibly be 
violent, there is not apt to be any lurking mischief, nor any malignant tend- 
ency. When short, very adhesive, and rather scanty, permitting the redness 
of the tongue to appear through it, and attended with some disposition to 
dryness, it is often a sign of a protracted and obstinate form of fever, which 
is apt to assume a low, nervous, or typhoid form. A yellowish hue of the fur 
is usually indicative of bilious disorder, being produced either by the vomit- 
ing of bile, or, what is probably much more frequent, by direct secretion from 
the tongue, consequent upon deficient secretion by the liver, or an excessive 
production of bilious matter in the blood. Not unfrequently this color of 
the tongue is accompanied with a bitter taste. It is common in miasmatic 
fevers and hepatic diseases. A brown or black tongue is usually indicative of 
a low state of the system and an impaired condition of the blood. It is owing 
to the secretion of a dark matter, apparently identical with that which collects 
about the teeth and lips in typhous fevers, and probably consisting of blood 
modified in its passage out of the vessels. The same action would seem to 
take place in the tongue as that which, in the stomach and bowels, occasions 
the black discharges so common in malignant fevers. It may depend on an 
enfeebled state of the secreting tissue, or a diseased state of the blood, or on 
both united. Very frequently this darkness of the tongue supervenes upon a 
previously white coating, and indicates a deteriorated state of the vital forces 
and probably of the blood. The caution should be observed, not to confound 
this discoloration with that which may proceed from accidental causes, as 
from the chewing of liquorice, tobacco, burnt coffee-grains, etc. In many 
instances, the white fur of the tongue is modified by red points, which are the 
tops of the swollen and projecting papillae. This appearance is not uncommon 
in eruptive febrile diseases, especially scarlet fever and measles. When con- 
sequent upon a dyspeptic state of the stomach, the fur is most copious in the 



THE TONGUE AND ITS DISEASES. 759 

Of local injuries, reference may be made to ulcers caused by jagged 
and projecting teeth-roots, to cuts and contusions from falls and 



morning before breakfast. In some persons, emptiness of the stomach is said 
always to induce this state of the tongue. 

"The manner in which a furred tongue becomes clean affords valuable 
indications. When the fur slowly recedes from the tip and edges, thinning 
gradually as it retires, it intimates a favorable convalescence. A portion of 
fur often lingers near the root of the tongue, long after the disease has given 
way. In another mode of cleaning, the fur loosens and separates in flakes, 
often beginning at the middle or near the root, sometimes in large patches, 
or over almost the whole tongue at once, leaving a smooth, red, glossy sur- 
face, as though the papillary structure had been lost. In such cases, if acute, 
and if the tongue remains moist, convalescence almost always takes place, 
though usually tedious, and sometimes very lingering. In threatening fevers, 
it is very desirable to witness this phenomenon ; and, as it is often preceded 
by a feeling of soreness in the fauces, this may be considered, when it occurs 
in such cases, as an auspicious circumstance. Much stress was laid upon this 
as a prognostic symptom by the late Dr. Joseph Parrish, of Philadelphia. 
Sometimes the fur recurs once and again, before it ultimately disappears; and 
weeks and even months are occasionally consumed in the struggling and 
apparently uncertain advance of the system toward health. In less favor- 
able cases, the tongue, after having commenced the process of cleaning, as 
just described, or even after completing it, instead of continuing moist, be- 
comes as dry as a chip, with an aggravation of all the symptoms, and no 
little increase of danger. The indication is still more unfavorable when, in 
addition to its dryness, the surface becomes gashed, chapped, or fissured, or 
exhibits a rough, scaly appearance. 

" This smooth, red, and glossy state of the tongue, sometimes with moisture 
and sometimes with dryness, is not uncommon in chronic diseases, in which 
it is generally a bad sign, and is supposed to indicate serious organic derange- 
ment of the alimentary mucous membrane. A still worse condition, how- 
ever, is an aphthous state of the tongue, which is apt to come on in the 
advanced stages of chronic diseases, and is generally to be received, under 
these circumstances, as a fatal sign, though of itself, and occurring in ordi- 
nary health, it is in no degree alarming. 

" A loss or depravation of taste is not uncommon, and is generally of little 
consequence, depending upon a mere derangement of the surface which re- 
ceives the gustatory impressions. But when of a paralytic nature it is much 
more serious, as it generally indicates disease within the encephalon. 

"The only other point requiring consideration refers to the movements of 
the tongue. When, in acute febrile diseases, these are not under the control 
of the patient, when upon being requested to protrude his tongue he is un- 
able to do so, or when the organ trembles much in the attempt, the symptom 
is exceedingly unfavorable, indicating either great prostration, or dangerous 
cerebral disease. Of similar unfavorable prognostication, under the same 
circumstances, is the occurrence of a difficult and hesitating utterance, like 



760 ORAL DISEASES AND SURGERY. 

blows, to bites inflicted under various circumstances by the teeth, 
to papular hypertrophies, to epithelial indurations and ulcerations, 
to stings from insects in fruit-season, to burns, scalds, the incautious 
or accidental mastication of acrid or irritating substances, to glossitis, 
from the excessive use of tobacco, from operations performed on 
neighboring parts, from mustard administered in strength in neces- 
sity for sudden emesis, etc. 

Of associate or constitutional diseases, the most prominent are the 
syphilitic and mercurial impressions appearing in the form of acute 
or chronic inflammations, indurations, fissures, ulcers, and cysts. 
Malignant manifestations, particularly the expressive scirrhus, have 
here also not unfrequently a first expression. 

With the almost exhaustive observations of the quotation from Pro- 
fessor Wood, given in the foot-note, is to be associated the fact that in 
some nervous, irritable persons the tongue is found habitually furred, 
yet without any symptoms of gastric or other derangement. Some 
persons get furred tongue the moment their stomachs are empty ; 
others have their tongues coated always after a meal and while 
digestion is going on, the coating passing away as the function 
ceases. Mental and moral emotions have a decided influence. 
Dr. Wright, in one of his clinical lectures, mentions the following 
striking illustration : 

" In calling upon a certain patient," says this gentleman, "the 
first thing I did was to look at his tongue. I found it, as usual, 
very pale, flabby, and moist, but without any coating. After having 
made other necessary inquiries, I was informed by my patient that 
his heart, which had long been disturbed by mental emotions, had on 
the previous evening beaten with unusual violence and irregularity. 
On my asking if he could account for it, he told me that he had just 
then received the distressing intelligence that an uncle, from whom 
he expected a competency, had not left him a shilling. This pitiable 
tale, told with much earnestness and visible feeling, occupied little 
more than twenty minutes. At the end of that time I again looked 
at his tongue, and found it coated with a thick, white fur." 

The most frequent disease of the tongue met with is perhaps 
syphilis. Syphilitic ulcers, the most common of the manifestations, 
appear on any part of the organ, but are most common on the sides 

stammering. The inclination of the tongue toward one side when pro- 
truded usually indicates palsy, and is one of the common attendants upon 
hemiplegia." — Wood. 



THE TONGUE AND ITS DISEASES. 761 

and under surface. Such ulcers are almost invariably accom- 
panied by associations of their origin, — psoriasis on the body, 
nodes, falling of the hair, lymphatic induration of the posterior cer- 
vical ganglia. A syphilitic ulcer on the tongue has the appearance 
of chancre, hard or soft: we meet with them where the ulceration 
is quite deep and the edges are heavily indurated. Again, where 
there is neither excavation nor induration, we nevertheless know, 
from the associations, and from the peculiar characteristic appearance 
of the base, that they are venereal. 

A second form of syphilitic disease of the tongue is observed in 
the induration and hypertrophy of circumscribed patches of mucous 
membrane. The induration in these cases is so markedly localized 
that, if it were not for their varying locations, — being always, how- 
ever, on the dorsum, — one might readily believe them to be enlarged 
circumvallate papillae ; the patches are quite as large as a dime piece, 
are elevated, and are as isolated as a fungiform wart. The author 
has seen two such patches on the dorsum of a tongue, and at the 
same time a large ulcer on its under surface. 

Cracks and fissures are other syphilitic indications met with on 
the tongue. It may happen in some instances that these fissures are 
so deep as to seem to divide the organ into a number of parts ; they 
always, so far as the author has observed, run lengthwise. These 
fissures are at times unbearably sore, denying the patient comfort 
either in eating or in rest. 

Indurations of the mucous membrane of the sides of the tongue 
from this cause are occasionally observed, or it maybe that a general 
thickening exists, or, indeed, that the whole organ is indurated. In 
this latter condition the disease has sometimes been mistaken for 
cancer ; but such an error could arise only from a failure to observe 
the associations of the case.* 

" Syphiloma (Gummata Syphilitica) of the Tongue. Dr. Neumann, of Vienna 
(Allgemeine Wiener Medizinische Zeitung, and Half-Yearly Abstract). — The 
dorsum of the tongue, as is well known, is frequently at its centre or lateral 
portions, more rarely at the root of the organ, the seat of infiltrations, — the 
so-called syphilitic gummatous tumors, the size, superficial aspect, and pro- 
gress of which undergo many variations. These tumors, which are of firm 
consistency, are seated partly under the mucous membrane, partly in the 
muscular tissue of the tongue, and are developed from small infiltrations of 
the size of a pea to prominent nodules as large as a bean or hazelnut, or even 
larger. The growth sometimes extends laterally, so as to form level patches : 
in cases of this kind a greater part of the tongue, especially its edges, feels 
thickened, infiltrated, and hard as cartilage. In this affection the mucous 



762 ORAL DISEASES AND SURGERY. 

Sometimes the dorsum presents red patches, the result, evidently, 
of a loss of the epithelial covering. These patches are perfectly 
smooth, not ulcerated, but are painfully sensitive to hot or cold 
impressions ; this condition will be met with where the dorsum 
seems literally skinned. By those familiar with the diagnostic 
description of the tubercular ulcer as insisted on by M. Tielert, 
it will be seen that with such a condition his premises become to a 
marked degree confused. 

To Prof. Sigmund we are indebted for the knowledge of the fact 
that the raw ulcerations on the sides of the tongue called syphilitic 
psoriasis are very contagious, a diseased child poisoning the nurse, 
and the diseased nurse poisoning the child by chewing its food first 
in her own mouth. 



membrane covering the growth is either smooth or covered by numerous 
papillary growths, which occupy a large portion of the tongue in the form of 
broad-based watery formations, or the surface of the dorsum may be trav- 
ersed by shallow furrows, or by deep fissures crossing in various directions, — 
rhagades ; or. again, if the mucous membrane be irritated by the sharp edge 
of a decayed tooth, it may present superficial patches of gangrenous tissue. 

"The whole volume of the tongue is increased to a considerable extent. 
Finally, the disease may proceed by softening of the nodules to a more or 
less extensive and deep loss of substance, in consequence of which the tongue 
on the affected side presents large cavities, which, when the loss of substance 
has affected the root of the tongue, exert a considerable influence upon the 
consonance of the speech. The movements of the tongue, also, as in speak- 
ing, masticating, and swallowing, cause much pain. These new formations, 
consisting partly of granulation tissue and partly of connective tissue, — 
which tissue, in its further development, becomes either soft and jelly-like, or 
is converted into adipose tissue, and forms dry yellow lumps, — were described 
by Eobin and E. Wagner as syphiloma. They present granular cell contents, 
and their cells and nuclei lie in peculiar hollow spaces — alveolar formation. 

: 'In cases of this kind one has to distinguish the infiltration of syphilis 
from that of cancer. Hardness, rapid growth, painfulness, and an uneven 
surface, are, indeed, symptoms which speak more for cancer than for syphilis ; 
the existence, however, of a sharply-defined loss of substance, and the pres- 
ence on the dorsum of the tongue of warty or condylomatous growths, are 
indicative of gummatous deposit. In cancerous growths of the size of syphi- 
litic gummata, the submaxillary glands would certainly be enlarged. In 
doubtful cases the diagnosis might be determined by means of the microscope. 
In some cases the distinction may be indicated by the course taken by the 
disease. In syphilitic gummata the breaking down of the tumor commences 
deeply, and proceeds to the surface ; in cancer the opposite takes place, loss of 
substance commences superficially, and gradually extends to the centre of the 
growth. :J 



THE TONGUE AND ITS DISEASES. 763 

The treatment of syphilis in the tongue has, with one special ex- 
ception, the twofold signification of constitutional and local, — the 
exception being that of chancre. It has without doubt occurred that 
a man has gotten a chancre upon his tongue. Mercury, in some of 
its various forms, seems to be looked upon by most practitioners as 
having in this direction something specific in its nature; without 
doubt, however, it is a greatly-abused medicine, and should be used 
with more caution and judgment than generally characterize its 
exhibition. 

Where ulcers or other manifestations upon the tongue are second- 
ary in their signification, and mercury has not been used upon the 
case, it is marvelous how at times, under its influence, such mani- 
festations can be made to disappear. How this medicine is to be 
used is perhaps best left to be directed by the apparent requirements 
of individual cases. Of one thing, however, we may be sure: its 
best effects are not to be obtained by salivating the patient. Mercury 
in the form of the bichloride is a favorite preparation ; it may be 
given in doses of the tenth to the twentieth of a grain dissolved in 
water or the fluid extract of sarsaparilla, three times a day. The 
hydrargyrum cum creta, combined with Dover's powder, is a combi- 
nation which may be used with benefit where dryness and other lack 
of function are found in the skin. Impression by inunction is another 
mode of exhibiting the medicine. A lump of mercurial ointment, 
the size of a large pea, may be rubbed into the inner face of the 
thighs night and morning. Calomel in quarter-grain doses, com- 
bined with small quantities of sugar to render it palatable, may be 
given every two or three hours, until the patient remarks the cop- 
pery taste. Blue pill, in five-grain doses, answers very well if there 
be no hepatic disturbance, as manifested by gastric derangement 
and sick-headache. 

Of the various mercurial preparations, the preference will be 
found to reside with the bichloride : in this form the impression of 
the medicine is gradually secured. If necessary, it may be given 
continuously for a month. 

Combined with the mercurials, it is a common experience that 
tonics are generally found indicated, — a something to counteract the 
degenerative tendency which appears to reside in every dose of a 
mercurial administered. Iron, quinine, gentian, and the red bark 
are excellent preparations. A prescription which will be found to 
be a very good one is as follows : 



764 ORAL DISEASES AND SURGERY. 

R. — Hydrargyri chloridi corrosivi, gr. iv ; 

Tincturse cinchonse composite, jfvj. M. 
Sig. — A teaspoonful three times a day. 

A second, admirable in cases associated with nervous disturbance, 
is the combination with the mercurial of the pyrophosphate of iron : 

R. — Hydrargyri chloridi corrosivi, gr. vj ; 
Syrupi ferri pyrophosphates, 3vj. M. 
Sig. — A teaspoonful three times a day. 

In syphilitic disease of the tongue, tertiary in its type, mercury 
will seldom be found admissible. The system is broken down : the 
process of cure must be one of regenerative repair. These are the 
patients for the sea-shore and the hill-side. You will not get them 
well if you cannot build them up. 

Conjoined with the tonic medication of these cases, very ex- 
perienced authorities commend, for its alterative influence, the use of 
the iodide of potassium. Where it is thought desirable to use this 
medicine, ten grains as a dose for the adult may be given three times 
a day. It is most conveniently exhibited in water, or, if taste is 
consulted, in the fluid extract of sarsaparilla. 

Tertiary symptoms, as M. Ricord observes, do not inevitably occur 
in the course of syphilis, but they are very likely to do so if the 
treatment of the primary and secondary symptoms be not conducted 
with the greatest care. As soon as the tertiary period has set 
in, mercury must be abandoned, and iodide of potassium given. 
Nay, further, as mercury taken in time may prevent or retard sec- 
ondary symptoms, and so may be regarded as a prophylactic against 
them, so may iodide of potassium be regarded as a prophylactic 
against tertiary symptoms ; and therefore M. Ricord, from the 
premises of his great experience, teaches " that to render the treat- 
ment of secondary syphilis complete and rational, it should always 
be followed by the exhibition of iodide of potassium. This substance 
is, however, not only useless when employed against secondary 
symptoms and those of transition, but very often hurtful ; yet, when 
secondaries have been of long standing, it may produce beneficial 
effects ; it is also useful as an adjuvant of mercury in those affections 
which in some degree lie between the secondary and strictly tertiary 
manifestations; and, finally, it is indispensable for combating the 
symptoms of a decided tertiary nature. In order to become well 
acquainted with the proper manner of administering the iodide of 



THE TONGUE AND ITS DISEASES. 765 

potassium, we should take the trouble of studying its effects, inde- 
pendently of its curative action. First let us see how it acts on the 
skin. It may produce on the cutaneous surface diverse psydracious 
and acnoid eruptions. The pustules are generally surrounded by a 
vividly red areola, and the usual seat of these eruptions is below the 
umbilical region, as the nates, thighs, etc., whereas the common acne 
(not to mention its other characters) is mostly situated in the upper 
half of the body. To these peculiarities, it may be added that the 
pustules will fall in immediately the administration of the iodide is 
interrupted. Exanthemata, impetigo, and lichen are very apt to be 
produced by the use of this salt ; and what you ought especially to 
keep in mind is, that ecchymosis and purpura in the inferior extrem- 
ities are sometimes caused by the action of the iodide of potassium. 
The effects of the latter on mucous membranes should also be care- 
fully observed. It may cause inflammation of the conjunctiva ; the 
submucous cellular tissue lying under gets infiltrated and puffed up ; 
the eyelids turn red and cedematous, and, when the inflammation 
and effusion are not arrested, the internal parts of the eye become 
involved in the affection, and photophobia is the result of this state 
of things. The normal mucous secretion is always a little increased, 
but it does not take the muco-purulent character, as in the case of 
catarrhal ophthalmia. Coryza, of a more or less severe nature, often 
exists at the same time ; it is preceded and accompanied by headache, 
and a pretty abundant mucous secretion ; but this coryza never 
reaches the suppurative state ; it never produces more than a catar- 
rho-serous flux. These affections never give rise to any fever, and 
they disappear as soon as the iodide is given up. This coryza is an 
accident which we should not overlook ; for it is of importance to 
avoid it when we have to treat a tertiary affection of the nasal fossae. 
As for the effect of the iodide on the intestinal canal, I have to state 
that persons enjoying good health can bear very large doses of it ; I 
have given as much as fifteen drachms a day. M. Puche has often 
given ten drachms per diem, after commencing with six ; and it has 
been noticed that it improves the appetite of the persons who use it. 
With some patients a certain pleurodynic sensation, corresponding 
to the cardiac extremity of the stomach, is felt after its ingestion ; but 
it never causes vomiting. The submucous cellular tissue of the 
stomach may, by the use of this iodide, undergo the same modifica- 
tions which we have noticed the conjunctiva to be subject to : a sort 
of hyper-secretion and intestinal ptyalism takes place, and much of 
the fluid which ought to have been secreted by the skin is rejected 



766 ORAL DISEASES AND SURGERY. 

by the mouth. This liquid has a slight taste of iodine ; it is not 
fetid in the least ; the gums are not swollen, and there is no fetor in 
the breath, as happens in mercurial ptyalism. The same effect may 
be produced on the other portions of the intestinal canal ; the patients 
are then seized with abundant serous diarrhoea. The iodine is elim- 
inated from the system by the kidneys ; half an hour after the inges. 
tion of it, its presence may be ascertained in the urine ; and it should 
be remembered that the presence of iodine in the blood increases the 
renal secretion. I have even observed a case of polydipsia which 
went on as long as the iodide was used, but disappeared when the 
latter was discontinued, and gradually sprang up again as the use 
of the salt was resumed. 

" The effects of the iodide of potassium on the circulation are of 
a sedative kind ; it diminishes the number of arterial pulsations, 
and lowers their force, but they may regain their normal standard 
if the remedy act beneficially on the system ; the same arterial en- 
ergy may also reappear when the iodide causes a slight phlegmasia. 
This salt is somewhat antiplastic ; for it has rather a tendency to 
liquefy the blood, and may even produce the peculiar hemorrhages 
of purpura. When the effect of the iodide on the nervous system is 
carefully watched, it is found to cause a certain excitement of the 
nervous centres, followed by a little uncertainty in the movements 
and in the intelligence." 

A combination much employed by Sir Astley Cooper, in cases 
where the iodide of potassium seemed not to favor the patient, was 
the liquor arsenici et hydrargyri hydriodatis, — Donovan's solution. 

Concerning the local treatment of the venereal affections of the 
tongue, with which, in a work like this, we would seem to have 
most to do, little is to be added outside of the suggestions offered 
on previous pages. The treatment is principally to be constitutional 
in character : direct medication is perhaps to be esteemed simply as 
palliative. 

As a local application of a common signification, lactuca sativa 
five ounces, honey one ounce and a half, and alum one drachm and 
a half, is a favorite with Ricord. Another consists of a decoction 
of hemlock, six ounces and a half, to bichloride of mercury, three 
grains. From my own experience, I have suggested the use of acids 
applied to the ulcers in cases where the dyscrasia has been corrected 
or nearly so. It is surprising with what rapidity a syphilitic ulcer 
will occasionally respond to almost any of the mineral acids. 

In a bad case of mucous tubercles I once treated, I got my patient 



THE TONGUE AND ITS DISEASES. 767 

well by daily salt-baths and the local use of a paint composed of 
sulphate of quinia and iron ; twenty-five grains of the former to 
two drachms of the muriated tincture forming the combination. 
The tubercles were painted twice a day for two months. 

Borax is a soothing application ; it may be rubbed with water 
into a cream, and thus be applied ad libitum. 

A species of local specific, to be used on the part and rinsed away 
after a few moments, is composed as follows: 

B. — Aquas destillatae, 5ixss ; 
Ferri perchloridi, 
Acidi acetici, 

Acidi t^drochlorici, aa 3j. M. 
This may be repeated three times a day. 

Fissures and fistulae are sometimes, in their chronic form, cauter- 
ized, nitric acid, pure or dilute, being used for the purpose. In a 
case of long-standing fissure of the tongue, the author on one occasion 
cut out the induration, the patient making a rapid recovery. 

Chloride of zinc, twenty grains to the ounce of water, will be 
found a useful application in chronic syphilitic conditions, whether 
of ulcer, fistula, or fissure. 

"In smokers and persons addicted to strong drinks or fed on 
irritating diet, the lips, cheeks, tongue, and especially the fauces, as 
pointed out by Dr. Charles Drysdale, and as has frequently been 
observed by the author, become the seat of interminable eruptions 
of mucous syphilitic lesions, just as in the external genitalia of 
women." These habits are not to be indulged in by persons so 
afflicted. 

Mercurial enlargement and induration of the tongue is a condition 
frequently demanding treatment. One of the t first effects of this 
medicine is often seen in the markings made upon the sides of this 
organ by an otherwise not observed swelling which has crowded it 
against the teeth. The tongue tumefied by the impressions of calo- 
mel may become so enlarged as to fill the whole mouth. One par- 
ticular case I recall, where, to prevent the patient from being smoth- 
ered, I was compelled to drag the tongue forward over the lower 
jaw, and thus fix it until relief could be otherwise secured. 

Mercurial ulceration of the tongue is another of the offenses of 
this medicine. Such ulcerations are in appearance indolent and yet 
irritable, and are associated with similar conditions of the gums, and 
with salivation : the diagnosis is very plainly marked. 



768 ORAL DISEASES AND SURGERY. 

The rational treatment of the mercurial conditions refers to the 
correction of the local impressions, together with elimination from, 
and support applied to, the system at large. In rapid swellings of 
the tongue, it may be found necessary to resort to the use of leeches 
combined with most marked derivation. In the case above referred 
to, forty common leeches were applied to the throat, the patient 
was profusely sweated, and these applications were succeeded by a 
saline cathartic. 

Such treatment, combined, if the circulation is sthenic, with some 
arterial depressant, as digitalis, aconite, or veratrum, will commonly 
relieve from the immediate danger. Unless, however, the ptyalism 
has been acutely excited, and the subject is strong and vigorous, 
this treatment will be succeeded by great lassitude and depression ; 
but such depression is a necessity, and has perhaps saved the 
life. 

A local treatment in cases of this kind is simply palliative and 
soothing. The lactuca sativa and honey, recommended in the syphi- 
litic sore-mouth, is an excellent gargle. Sage-tea, combined to a 
full saturation with chlorate of potassa, is another agreeable ap- 
plication. Common table-tea is very grateful to a patient. In 
combination with these, or any similar demulcent gargle, great relief 
has been derived from the free exhibition, internally, of the bromide 
of potassium. 

B. — Potassii bromidi, 3ss ; 
Aqua3, ^viij. M. 

Sig. — Tablespoonful repeated occasionally as the patient is found 
nervous. Twenty grains, as here directed, may be prescribed three 
times a day at the least. The author has given eighty at a single 
dose. 

The acute conditions of a mercurial glossitis combated, the prac- 
titioner may find it desirable to attend to the more general require- 
ments of the case. The system is to be protected against further 
impressions of the agent, while at the same time it will generally 
be found that a present support is demanded. Chlorate of potassa, 
the antagonist of the mercurials, has now obtained in this direc- 
tion an almost universal use : it may be administered in full satu- 
ration, in tablespoonful doses, three or four times a day. A very 
good way to prescribe this salt is to order one ounce placed in an 
eight-ounce bottle, which is to be kept filled with water until all is 
dissolved. As each dose is taken, the patient replaces it with fresh 
water. 



THE TON&UE AND ITS DISEASES. 769 

In the treatment of the mercurial ulcer, the local applications 
suggested have been various. Bismuth, red bark, and borax, in 
equal proportions, act sometimes very happily. Chlorate of potassa, 
tannic acid, and glycerine form another excellent combination. Solu- 
tions of sulphate of copper or zinc, one grain to the ounce of water, 
are cleansing and stimulating applications. Iron, opium, chalk- 
powder, aromatic powder, are all, in their turn and place, useful. 
If phagedena intervene or threaten, the potassio-tartrate of iron, as 
recommended by Ricord in the similar ulcers of syphilis, is not to 
be omitted : it may be used in the strength of thirty grains to the 
ounce. It should also be administered internally in doses varying 
from five to ten grains repeated every two hours. 

Chronic phagedasna, which in some degree associates itself more 
or less frequently with mercurial ulcers, is best treated by the poten- 
tial cauterants. Of these, a favorite is creasote: this is to be applied 
with care, however, as it may provoke secondary inflammation. 
Carbolic acid is a useful article, and will sometimes prove very 
reliable. Nitric and hydrochloric acids are highly recommended 
by many practitioners: when applied, every recess of the sore is to 
be burned, and this should be repeated daily until healthy granula- 
tions are provoked. 

Sctrrhus. — Of the third form of constitutional impressions, 
scirrhous carcinoma may now engage our consideration. This 
scirrhus of the tongue, from the circumstances of its association and 
position, is to be deemed a necessarily dangerous, if not fatal, disease. 
Scirrhus in other parts may be cured ; that is to say, being removed, 
it may not reappear in the part of removal, — although, being a con- 
stitutional condition, the disease is seldom, if indeed ever, perma- 
nently destroyed. That scirrhous carcinoma is not, however, at 
least in its incipiency, so formidable an expression as the encephaloid, 
seems to be the universal impression: there is a fixedness, an appar- 
ent isolation about it, which always invites operation ; that is to say, 
as is expressed in the chapter on Tumors, it exhibits the existence 
of an antagonism on the part of the vital force which invites and 
promises good from assistance. 

Situated in the tongue, such isolation is, however, unfortunately, 
not so marked as when found in many other parts: the disease ap- 
pears here as an induration rather than as what might be termed 
a lump, and this induration has not, commonly, a definite boundary; 
hence, if it be removed by operation, one is at a loss to say whether 
such removal has been complete. 

49 



770 ORAL DISEASES AND SURGERY. 

A carcinomatous scirrhus is to be distinguished from scirrhus of 
local signification, — first, by its resistance to treatment ; and, second, 
by the peculiar darting, lancinating pains which, sooner or later, 
always appear in it; these pains are markedly diagnostic. Again, a 
scirrhous carcinoma is apt to have a hereditary history : a generation 
may have escaped, but it is apt to be discovered somewhere in the 
family. 

Local medication to a carcinomatous scirrhus is perhaps worse 
than useless. If it is not widely cut away, it is better, a hundred 
times, to let it alone. Many a tumor of this class that would have 
remained dormant for years has been excited to the most destructive 
malignancy by over-officious meddling with it. If a practitioner does 
not know the character of a tumefaction upon a tongue, he cannot 
act more wisely than in doing nothing at all, until, at least, time and 
continued observation have made the diagnosis plain to him. 

At a period very various as to time, a scirrhous carcinoma ulcer- 
ates. If the tumor has attained any size, fungous granulations 
sprout forth, giving that expression known as fungus haematodes ; 
if, on the contrary, the tumor ulcerates while small, it is irregular, 
puckered, everted in its edges or elevated, and covered with abun- 
dant granulations : the discharge may be thin and sanious, or 
purulent, the latter character being, however, rare : it differs from 
the syphilitic sore in its granulative bottom. 

A section of scirrhous carcinoma presents a stroma dense, abun- 
dant, and closely meshed. A fibrous struc- 
ture is always more or less marked, par- 
ticularly in its occult state, such structure 
assimilating both the white and yellow 
tissues, being perhaps really these tissues. 
A diagnostic sign is a peculiar creak or 
cry given under the knife. Another is a 
shrinkage or contraction in the centre of 
a section. Still another is a creamy juice, 
which may often be scraped from it. 
In looking at a microscopic slice of 

A microscopic view of the cancer- . . . ,, , . ,. 

cells suing the interstices among scirrhous carcinoma, the areolae existing 
the bundles of the fibro-ceiiuiar in the stroma are found filled with gran- 
tissue in the skin of the breast. i -, . -. 1 j i n , 1 
Magnified about two hundred times. uleS > DUclei > aDd nucleated cells : these 

(After Paget.) cells being of most diversified form and 

common to no tissue, the term heteroclitic is justly applied to 



Fig. 242. 




THE TONGUE AND ITS DISEASES. 771 

them. The appearance of such a section is exhibited in the engrav- 
ing, Fig. 242.* 



*" It is well known that whenever a special predisposition to abnormal 
action exists in the vital economy, a very slight thing is sufficient to act as an 
exciting cause of disease. This is especially the case in many affections of 
both an organic and dynamic character, examples of which we have occa- 
sionally presented, among which was the apparent development of cancer 
from the irritation produced by rough or decayed teeth. Additional evidence 
upon this point is furnished by the following cases from the clinical report on 
epithelial cancer, by Mr. Jonathan Hutchinson, in the Medical Times and 
Gazette: 'George P., aged thirty-six, a dark, sallow, but healthy-looking 
man, was admitted, December 29, 1853, into St. Bartholomew's Hospital, 
under the care of Mr. Stanley, for a cancerous ulcer in the middle of the right 
margin of the tongue, about an inch in length, half an inch in width, and 
half a line to a line in depth. The base was irregular, not granular, nor dis- 
tinctly nodular or warty ; it was clean and moderately florid, and while in 
the hospital, and being guarded from the teeth by an ivory cover for them, 
it became level, and skinned over very thinly, yet enough to prevent its 
bleeding when lightly rubbed. The borders of the ulcer were upraised, with 
a somewhat lobed or glandular surface. This was especially the case with the 
upper border, which, occupying a portion of the dorsum of the tongue, over- 
hung a little the adjacent mucous membrane. The elevated border felt firm, 
tense, and nearly hard ; the base of the ulcer was equally so, and these char- 
acters were evidently derived from morbid deposits at and for about two to 
three lines beyond the ulcerated surface. At the border this deposit did not 
involve the very surface-layer of the mucous membrane, which was tensely 
stretched over it, but discernible with its small vessels. The rest of the 
tongue appeared to be all healthy. One lymph-gland by the side of the facial 
artery was slightly enlarged, firm, but not hard. The teeth by the side of the 
ulcer were not rough, but neither were they clean, and, as already said, the 
ulcer became smoother and skinned over when protected from them. 

" ' He said that nine months previously his tongue had become sore through 
the "fretting" of a decayed tooth at this part. He allowed the tooth to re- 
main for six months, the sore extending all the time until it had reached its 
present dimensions. At length, three months ago, the tooth was drawn ; the 
sore remained, and he was not aware of any change in its character. It was 
always very painful, and the pain extended from it over the whole cheek and 
the side of the head and jaw. Many of the cervical lymphatic glands under 
the right side of the jaw had been enlarged, but they had subsided two months 
previously ; and the one by the facial artery had only in the last week been 
enlarged. His great-aunt died of cancer of the throat (sufficiently proved) ; 
but no other relative was known to have had cancer. He never had any 
syphilis or well-marked struma. ' 

"After an ineffectual effort to remove the disease by constitutional treat- 
ment with iodide of potassium, the part was excised : the troublesome symp- 



772 ORAL DISEASES AND SURGERY. 

As scirrhous carcinoma always begins upon the sides of the 
tongue, jagged and sharp teeth irritating the parts may be supposed 
to have some influence in its localization; such teeth, under all cir- 
cumstances, should be removed or smoothly dressed. 

In the treatment of scirrhus of the tongue by amputation, several 
modes are employed. One, that of the French school, is by means 
of an instrument known as the ecraseur of Chassaignac. This is 
simply a delicate chain arranged from a handle, which little by little 
crushes off the part. Another mode, that of strangulation, consists 
in the introduction of circumscribing ligatures, which, being drawn 
tightly, cut off all circulation from the diseased part, thus compelling 
its separation.* Another means of treatment widely employed, and 
in instances recommended by very high authority, consists in the 
use of caustic remedies ; of these there is a great variety, — arsenic, 

toms subsided, the patient recovered, and is still in good health, — eleven 
years after the operation. 

" ' Caroline C, aged thirty-five, a married woman, and the mother of three 
children, was admitted, February, 1855, into Middlesex Hospital, under the 
care of Mr. De Morgan. She was subject to dyspepsia; but during the last 
few years she had been in rather better health. She had broken teeth on the 
right side of her mouth, which had irritated the tongue. Two years before her 
admission she noticed that her tongue was sore, and a year ago a lump began 
to form in it. Mr. De Morgan removed the right side and tip of the tongue 
by ligature. He made an incision in the median line beneath the jaw, and 
dissected his way upward, and then, having passed the ligature, tied it over 
a wooden bridge, which was fixed as a sort of tourniquet. In ten days or a 
fortnight it had separated. On March 19 both the wound below the jaw 
and that of the tongue were quite healed. There was then, however, suspi- 
cious hardening about the cicatrix. The disease soon afterward returned in 
the stump, and in the course of a few months the woman died.' 

"'Daniel H., aged forty-six, was admitted, November 2, 1860, into St. 
Thomas's Hospital, under the care of Mr. McMurdo. He stated that twelve 
months ago he experienced a soreness of his tongue on the left side, which 
he imagined was due to irritation of some decayed teeth. Several had been 
removed in consequence, but nothing was done for the tongue. The ulcer in 
the latter grew more painful, and five months ago the glands below the jaw 
began to enlarge. There is at present an ulcer on the left and under side of 
the tongue. This half of the tongue is hardened, swollen, and very painful ; 
and he speaks with great difficulty, from pain in moving the tongue, which 
is also not able to be much moved, from being swollen and tied down by the 
ulceration and induration. He suffers a great deal of pain. His health has 
generally been good, and he says that, except for the local distress, he feels 
well. He is, however, very sallow, haggard, and emaciated.' " 

* See operations on a succeeding page. 



THE TONGUE AND ITS DISEASES. 773 

however, forming the base of most of them. No remedies require lo 
be used with more judgment and caution. If the practitioner desires 
to try a caustic, my own experience would suggest chloride of zinc : 

B. — Zinci chloridi, 

Aluminis pulveris, aa gr. v; 
Acidi tannici, gr. ij ; 
Ferri persulphatis, gr. iij ; 
Grlycerinse, q. s. for a paste. M. 

To apply this paste, draw the tongue forward, hold, and dry it 
carefully in a napkin. Lay some crystals of zinc on the part, and 
cover over with the paste. This may be allowed to remain as long 
as the tongue can be kept dry. Finally, wash the debris away, and 
the application is completed. 

It may happen, after such an application, that severe general 
glossitis will supervene; this will be unfortunate, and will imply 
that much more harm than good has been done. In making a 
caustic impression under such circumstances, the parts should be 
quickly killed, not excited and provoked. 

The galvanic cautery, a means suggested originally by Heider, 
and lately made quite practical by Hilton, is thought by many to be 
greatly preferable to the potential cauterants : this consists of a long, 
delicate-bladed forceps transmitting copper wires, which, being 
applied to the part to be acted upon, are instantly heated by the 
galvanic current, thus destroying the vitality of the part outright. 

Injection of persulphate of iron is still another means much em- 
ployed and commended. My own experience with it, however, has 
not led me to look upon it as a specific. 

The arrows of Maisonneuve, tipped with zinc, may be used by 
those who do not fear a resulting inflammation. Two, three, or 
more of these arrows may be made to circumscribe the tumor, pre- 
cisely as practiced by this surgeon in his operations upon the mam- 
mary gland. 

Epithelioma.* — Except as situated upon the lower lip, in no situ- 
ation has the author more frequently met with epithelioma of cancer- 

* To the histologist, who, judging entirely of the character of a patho- 
logical new formation by its cell expression, the distinction here assumed 
between scirrhus and epithelioma will serve to exhibit the author as not 
accepting the assumed identity of the conditions. What he has to say on this 
subject will be found in the chapters on Tumors. 









774 ORAL DISEASES AND SURGERY. 

ous expression than upon the tongue. Situated upon the sides and 
along the frsenum, the disease is commonly first noticed as an irreg- 
ular puckered patch of more or less hardness, and almost from the 
very beginning has associated with it a characteristic pain. More 
frequently than otherwise, instead of one patch, a sufficiently close 
observation will discover the affected side studded, — a matter which 
is not long in being made evident enough to the patient. After a 
time, differing in different individuals, these patches sprout forth the 
giant granulations so characteristic of this disease, the surface of the 
sore becoming foul and ragged, and inclining to spread over neigh- 
boring parts. In a case at present under the care of the writer, in 
which preparation is being made for the amputation of the full 
tongue, the disease exists as an infiltration, involving the entire right 
half, but not passing the raphe. 

In no cases of disease does there seem to exist greater reluctance 
on the part of the general practitioner to the admission of the exist- 
ence of a fatal malady than in this of epithelioma of the tongue ; and 
this, perhaps, is not to be wondered at, seeing that not unfrequently 
an ulcer of such signification will lie in a dormant condition for a 
period of several months, looking to the inexperienced scarcely as 
formidable as a syphilitic sore. Such oversight is always of lament- 
able consequence, as thus the most promising period for the em- 
ployment of operative means has been suffered to pass without 
advantage. 

Cancerous epithelioma, so frequently confounded with syphilis, 
is to be distinguished from the latter expression not only by its 
location, but with most assurance by its appearance ; the first being 
characterized by isolated giant granulation of rough surface, the 
latter by a soft, pasty base. The two are really very unlike, and 
should deceive no one: even the primary chancre here sometimes 
found bears no resemblance to epithelial carcinoma. 

The progress of lingual epithelioma of this expression is of the 
most distressing character: the organ enlarges and stiffens, masti- 
cation and deglutition become functions of most difficult and painful 
performance, the saliva dribbles constantly over the chin, and the 
patient finally perishes from starvation and exhaustion. 

Cancerous epithelioma of the tongue must either have attempted 
with it the most radical extirpation, or be soothed into quiet, and 
into such abeyance as is possible to be secured. Of the latter means, 
advantage has been taken of a partial paralysis, securing immunity 
from pain through section of the lingual nerve ; while it has also 



THE TONGUE AND ITS DISEASES. 775 

been deemed that much control over the progress of the disease 
has been secured by ligation of the lingual artery of the affected 
side. 

In the practice of the author, where operative means of any class 
have not been thought advisable, the patients have expressed them- 
selves as receiving the greatest relief from the local employment, by 
means of an atomizer, of the following combination : 
R. — Acidi carbolici fluidi, 5j 5 
Sodas sulphitis, % ; 
Aquae, %x. » 

Systemic lingual epithelioma most frequently makes its appear- 
ance either at the side of the base of the organ or near the tip. 
Frequently, however, where jagged teeth exist in the arch, it may 
arise as an abrasion, the location being without doubt influenced 
by the irritant. Such a lesion is not apt to be appreciated in its 
true character until its refusal to heal after the extraction of the 
offending tooth is noticed. Still another cause of localization in 
this direction arises from a malarticulation of the posterior teeth, 
the tongue on each occlusion being caught and fretted. The 
peculiar articulation referred to is to be seen when the molars of 
both jaws incline inward, striking above at the buccal angle and 
leaving a space with the base locking inward. The author has at 
the present time under his care two cases of lingual epithelioma 
which have been thus located. 

Tubercle. — Scrofula, as a dyscrasia, differs from tuberculosis in 
not being the expression of a materia peccans. Tubercle repre- 
sents a specific condition, the scientific cure of which must lie in 
the discovery of an antidotal specific. Tubercle has been discov- 
ered as a deposit in almost every organ of the body, being, how- 
ever, as uncommon to the tongue as it is the reverse to the 
lungs. The existence of lingual tubercular tumor is not, however, 
to be doubted, the microscope revealing all the elements of the 
expression so fully studied in the examinations of Langhaus. A 
tubercular tumor of the tongue finds its diagnosis most simply in 
association: the finding, for example, of tubercle in the lungs, the 
mesentery, or other parts. Also, when it appears in children, it is 
to be judged from its so frequent association with scrofulosis. The 
child will be likely to have tumid, pouting lips, the lax, protuberant 
abdomen, etc. Still again, as time advances, the diagnosis becomes 
verified by the rapid tendency to break down and create an indolent 
resisting ulcer. 



776 ORAL DISEASES AND SURGERY. 

In the treatment of the tuberculous tumor or ulcer, the iodine 
preparations, by universal consent, have come to be most relied on, 
in this medicine being found the nearest approach to a specific. 
In the absence of a complete specific, however, it is most important 
to afford to the vital force the greatest possible amount of resistive 
power ; and this is to be done only by an attention to, and an ob- 
servance of, those common hygienic and dietetic laws which keep 
well people in robust health. 

The local treatment of lingual tuberculosis consists in the use of 
stimulating applications to the part, the best of which agents would 
seem to be iodine in tincture. M. Trelat, a French surgeon, recom- 
mends touching such ulcers with the actual cautery, affirming this 
treatment to be the only one ever found of service in his own prac- 
tice. 

Cystic Tumors. — Cystic tumors of the tongue, while not, as I 
am now satisfied, frequent, are yet not sufficiently rare to make 
allusion to them unnecessary. That known as meliceris is round, 
free from pain, and filled with a glutinous, honey-like substance. A 
peculiarity of this cyst is the fungiform character of its bottom, this 
portion looking pyogenic. A second order of cysts contains lymph, 
sometimes fairly colloid in consistence and appearance, at other 
times flaky, tubercular, or, it may be, puriform.* 

* " There is a disease of the tongue which I have seen every now and then, 
and which I am sure is very often mistaken for cancer, though it is of a dif- 
ferent nature. It is a curable disease, although it looks like a malignant one 
in many respects. The first thing of which the patient complains is enlarge- 
ment of the tongue, with some pain. On examination, you find a tumor in 
one part of it, not very well defined, nor with any distinct margin. It is a 
softish tumor, and increases in size, and perhaps another tumor appears in a 
different part of the tongue, and that increases also. There may be three or 
four of these soft elastic tumors, with no very defined margins, in various 
parts of the tongue. This is the first stage of the disease. 

" In the second stage there is a small formation of matter in one of these 
tumors, — a little abscess, which breaks externally, discharging two or three 
drops of pus. When the abscess has burst it does not heal, but another forms 
in one of the other tumors. These abscesses may assume the form of ulcers, 
and the ulcers have a particular appearance. In the first instance it is a very 
narrow streak of ulceration, but on introducing a probe you find that the 
ulcer is the external orifice to a sort of fissure in the tongue. The probe 
passes in obliquely ; the tongue is, as it were, undermined by the ulcer, a flap 
of the substance of the tongue being over it. 

" The disease now becomes more painful, and at last the ulcers may spread 
externally. In some instances they occupy a very considerable portion of the 



THE TONGUE AND ITS DISEASES. 777 

A form of cystic tumor, being a cystiform hypertrophy of a cir- 
cum vallate papilla, is met with occasionally on the back part of the 
dorsum. These tumors have been known to attain the size of a 
walnut. To the touch they are very solid, the walls being greatly 
indurated. If satisfied that there is no malignant association, the 
practitioner may puncture the sac and introduce a tent. Iodine 
may be used both externally and by injection. Ranular cysts, fre- 



surface of the tongue, but generally they burro'w internally, and do not spread 
much toward the surface. This is a very distressing state of things, and a 
man may remain in this state for a long time. The glands of the neck do 
not become affected, nor does the general health suffer, except from the diffi- 
culty of swallowing food. This is one inconvenience experienced by the 
patient; and he also labors under a difficulty of articulation. The tongue, 
from its enlarged state, may become stiff, not sufficiently pliable for the pur- 
poses of speech, and the patient either speaks thick or lisps. 

" In some instances the disease may be relieved by a course of sarsaparilla, 
with small doses of bichloride of mercury. A strong decoction of sarsaparilla, 
with from a quarter to half a grain of bichloride of mercury, may be taken 
in the course of the day. Of course, if there be anything wrong in the gen- 
eral health, you should endeavor to get that corrected, and attend especially 
to the state of the bowels and the secretion of the liver. If the secretions of 
the digestive organs be unhealthy, a dose of senna and salts may be given 
every other morning, and blue pill every other night. When the patient is 
brought into this state, one remedy, as I have said, is sarsaparilla with 
bichloride of mer*cury ; but, according to my experience, this is not the best 
remedy. The remedy best adapted for these cases is a solution of arsenic. 
Give the patient five minims three times daily, in a draught, gradually in- 
creasing the dose to ten minims. It should be taken in full doses, so that 
it may begin to produce some of its poisonous effects on the system. When 
it begins to act as a poison, it will show itself in various ways. Some- 
times there is a sense of heat, a burning pain in the rectum ; sometimes 
griping, purging, and sickness, and nervous tremblings. A patient who is 
taking arsenic, especially in pretty large doses, ought to be carefully watched. 
At first you may see him every two or three days, and then every day ; and 
as soon as the arsenic begins to operate as a poison, leave it off. When this 
effect is produced, the disease of the tongue generally gets well ; but at any 
rate leave off the arsenic, and the poisoning will not go too far ; it will do no 
harm. If, after a time, you find that the disease is relieved, but not entirely 
cured, you may try another course of arsenic. Perhaps it may take a consid- 
erable time to get the tongue quite well. Sarsaparilla, with the bichloride 
of mercury, may be given at one time ; and at another, arsenic. You cannot 
give either of these remedies forever, and indeed the arsenic can only be given 
for a very limited period; but it is astonishing what bad tongues of this de- 
scription I have seen get well under these modes of treatment, especially 
under the use of arsenic." — Brodie. 



778 ORAL DISEASES AXD SURGERY. 

quently described as lingual cysts, are classified by themselves. (See 
Banula.) 

Acute Glossitis. — Acute inflammation of the tongue, whether 
of idiopathic or of traumatic character, is always to be looked on 
with concern. The causes inducing this condition are various. 

Viewed as a distinct condition, — and this view, no matter what 
the cause, will always force itself on the attention of the practitioner 
when called to a case, — the most urgent necessity will nearly always 
be felt for a treatment that shall abort or resolve the phenomena as 
quickly as possible. It is true that all glossal inflammations are not 
dangerous ; but they all inspire with a sense of danger. 

Acute glossitis, idiopathic in form, commonly begins with a sense 
of enlargement and stiffness of some part of the organ, generally 
the anterior part; this soon becomes red, painful, and perceptibly 
swollen. At this stage the condition may rest, and after some little 
time commence to decline. On the other hand, a single hour may 
witness the spread of the inflammation to an extent which shall 
threaten or perhaps produce suffocation. In still other instances 
the advance is gradual ; the circulation sympathizing, the pulse grows 
rapid and irritable, the skin becomes hot, only to decline to the cold 
sweating stage; and suppuration or perhaps gangrene terminates 
the action.* 

* " Glossitis, Acute. — Michael M., aged thirty-six years, employed as ajboat- 
man by the Barrow Navigation Company, presented himself at the Meath Street 
Dispensary, Dublin, on the 14th of January, 1871. His appearance was charac- 
teristic of the affection from which he suffered. His countenance was anxious, 
the tongue protruded between the teeth, his speech was thick, or what might be 
termed the glossitic speech ; his breathing was distressed. On inquiry, he ascer- 
tained that the man had got a severe wetting some days previously, and had 
his feet also immersed in water. He shivered, and felt a soreness at the root 
of the tongue. He had not been taking any medicine, and up to the time of 
severe wetting was in robust health. In addition to the symptoms detailed. 
he had a dribbling of saliva from the mouth, with headache and dysphagia. 
The pain in the tongue, as the disease advanced, was described by him as of 
a stinging nature. On examination, he (Mr. Croly) found the tongue cov- 
ered with a white exudation, like a false membrane. The organ was large, 
protruded, and exquisitely tender to the touch. The sublingual space was 
infiltrated and chemosed, and the fringe beneath the tongue resembled a 
cock's comb. The tonsillitic regions were natural, and bore pressure without 
causing any uneasiness. He got the patient to open his mouth sufficiently to 
enable him to introduce his little finger, and the man winced when he de- 
pressed his tongue. He observed that the palate and tonsillitic regions, as 
seen internally, were not in the slightest degree altered. He considered from 



THE TONGUE AND ITS DISEASES. 779 

The dangerous character of a severe glossitis demands the most 
energetic treatment. Leeches direct to the organ or beneath the 

the patient's general symptoms, and the infiltrated condition of the tongue, 
caused by the exudation of lymph in addition to the engorgement with blood 
and serum, that no time should be lost in giving him relief by the knife. He 
accordingly introduced a sharp-pointed bistoury far back, and made a free 
incision at each side, parallel with the raphe. The wounds gaped and bled 
freely, and the patient's speech became suddenly better. He next punctured 
freely the chemosed sublingual space. A warm bath and a purgative draught 
were prescribed, and he warned the man against cold, and recommended him 
to come into hospital, but he declined. On the following day he called at the 
dispensary, and was much improved. The tongue was still tender to the 
touch, but the symptoms were so much relieved that, notwithstanding his 
advice to the contrary, he returned by boat to the country that evening, and 
he had heard nothing of him since. The notes of the next case to which he 
would call their attention were sent to him by Dr. Barry, of Kanturk. He 
visited a man, aged forty, whose respiration, articulation, and deglutition 
were very painfully affected. His tongue protruded between his teeth, and 
was so engorged as to fill all the space up to the palate ; and the tissues from the 
chin to the larynx were infiltrated. With some difficulty, Dr. Barry intro- 
duced a long and narrow bistoury on the flat, and, having turned the blade on 
its edge, he made two longitudinal incisions parallel to the raphe, with in- 
stantaneous relief. There was a copious flow of blood, which relieved the 
danger of impending suffocation, and the patient recovered in a few days, and 
was now in good health. The notes of the following three cases were kindly 
given to him by Dr. Deeper, of Keady. Dr. Deeper called the cases ' Glossitis.' 
The first was followed by an attack of delirium tremens, and after that by 

diffuse inflammation of the left leg. Mr. , of full habit of body, a free liver, 

of intemperate habits, dined at a club with seven friends on New Year's eve. 
He left the hot dining-room late, and drove home, a distance of six miles, the 
night being bitterly cold and frosty. Next morning he awoke with sore 
throat, some difficulty of swallowing, and had a dry, parched, and swollen 
tongue. These symptoms rapidly increased, and Dr. Leeper was asked to see 
him at ten o'clock a.m. The tongue was then greatly swollen, filling up the 
mouth, and protruding an inch between the teeth. It was of a dark-brown, 
almost mahogany, color. The sublingual glands were swollen, and the sub- 
lingual spaces filled up to a level with the incisors. The submaxillary glands 
were not much affected. It was impossible to see either the tonsils or fauces ; 
but the roof of the mouth was covered with red erythematous patches. When 
the tongue was well moistened he could swallow and speak without much 
difficulty. Six leeches were applied to the under surface of the tongue and 
sublingual space. They rapidly filled themselves, and from the bites there 
was a very considerable flow of blood, which gave immediate relief. Before 
two hours he could keep the tongue in the mouth, and swallow with ease. Dr. 
Leeper considered that the leeching, purging, and sudden withdrawal of his 
accustomed stimulant and food brought on an attack of delirium tremens. 



780 ORAL DISEASES AND SURGERY. 

jaw, bleeding from the arm, catharsis, diaphoresis, — any or all of 
these means are successively to be brought into requisition. A plan 

The next case was one of acute glossitis, treated by free incisions on the dor- 
sum of the tongue. P. R., a farm-laborer, was attending a corn-mill, getting 
oatmeal prepared. When there, he assisted the kilnman in turning the oats 
when drying, got into a profuse perspiration, and soon afterward exposed 
himself, on a cold, biting day in March, and was chilled. This was followed 
by swelling of the tongue, and difficulty of swallowing. Dr. Leeper saw him 
the next day. The tongue was greatly swollen, especially at the back part ; 
there was an abundant flow of saliva from the mouth, and the surface of the 
tongue was covered with a dirty-white, creamy-looking paste. He was speak- 
ing thick, and said he would soon choke if not relieved. There was no en- 
largement of the tonsils or the submaxillary glands. Dr. Leeper made with 
a lancet, the only instrument he had with him, two incisions on the dorsum 
of the tongue, parallel to the raphe. There was a discharge of four or five 
ounces of blood and serum from these incisions. He received a message next 
day to say that the man was much worse, and on visiting him found the 
tongue more swollen, protruding from the mouth, and that deglutition and 
speech were more difficult than on the day before. He introduced a sharp- 
pointed bistoury, and made two long and pretty deep incisions on the dorsum 
from the base to the tip of the tongue. These bled profusely, and gave im- 
mediate relief, and the next day the patient could swallow without difficulty, 
but the speech was thick. His recovery from this time was rapid. In the 
third of Dr. Leeper's cases, the patient was forty-five years of age. After 
exposure to cold he complained of pain and deafness in the right ear, and 
these were soon followed by difficult}' of speaking. These symptoms, after 
having lasted upward of a fortnight, were succeeded by rapid swelling of the 
right side of the tongue. When Dr. Leeper saw him, there was a profuse 
flow of saliva, so much so, that he thought he must be laboring under the 
influence of mercury ; but there was no mercurial fetor, nor were the gums 
affected. The right side of the tongue was as much affected as it could be, 
but the left was not engaged. The tonsils were not enlarged ; neither the sali- 
vary nor the submaxillary glands were swollen. The root of the tongue was 
hard and swollen. Any attempt to swallow was followed by a squirt through 
the nose and mouth, with coughing. It seemed as if the epiglottis could not 
act, and that the fluid passed into the larynx. Some milk was injected (by 
means of a large elastic catheter attached to an elastic bag) into the oesopha- 
gus. He sometimes succeeded in swallowing, but the attempt far oftener 
failed, and was very distressing to him. Dr. Leeper made a free incision, on 
the dorsum, from the back to the tip of the tongue on the right side, but the 
discharge of blood was inconsiderable, less than he could have supposed from 
the extent of the incision. Fomentations with hot chamomile-tea were used 
and kept in the mouth, and his health supported as well as possible with milk 
and beef-tea. Next day he was worse, and Dr. Leeper made a still deeper and 
more extensive incision on the right side of the tongue. There was no dis- 
charge of blood or serum, at least not more than two ounces, and no relief 



THE TONGUE AND ITS DISEASES. 781 

of treatment, as reliable as any in character, is as follows : place 
on the back of the neck a cataplasm of mustard and red pepper; 
put the feet in water as hot as can be endured ; give a full dose 
of sulphate of magnesia. If now the disease does not seem to be 
held in check, wrap the patient in shawls or in blankets and admin- 
ister spirits of Mindererus until full diaphoresis is secured. If even 

from it. Mr. Young, of Monaghan, saw the patient the next day, and ad- 
vised leeches to the side and under surface of the tongue. These induced 
profuse bleeding, which was kept up by cold water in the mouth, Dr. Young 
thinking that cold water promoted bleeding from leech-bites better than hot. 
The swelling of the tongue subsided at once after the leeching, but the right 
side of it remained thicker and harder than the left, and the man's speaking 
was still difficult and imperfect. Mr. Croly proceeded to say that it was 
superfluous to go into the subject more fully, as it had been already discussed 
at a previous meeting. He would only state that he thought the case, he had 
detailed was a very well-marked case of idiopathic glossitis. The man work- 
ing on a river and getting a severe wetting, not taking any mercury, the 
tongue becoming greatly swollen, the characteristic voice, the absence of any 
tonsillitic inflammation, — all these features showed that it was a typical case 
of idiopathic glossitis. 

" Mr. Kichardson said he had a case of this kind a short time ago in the 
Adelaide Hospital. There was rapid swelling of the right side of the tongue 
and chemosis of the floor of the mouth. In that case he not only made an 
incision from the base to the point of the tongue, along the dorsum, but he 
also made a few punctures in the chemosis on the floor of the mouth, and the 
man was well in a few days. An exfoliation of mucous membrane followed, 
which, however, did not interfere with recovery. As there was some doubt 
regarding the period at which the treatment by long incisions was introduced, 
he wished to state that he had found in the Memoirs of the French Academy 
of Surgery several cases of this kind recorded. In one of these cases, pub- 
lished by De la Motte in 1725, the tongue became greatly swollen in less than 
five hours. It soon filled the mouth, and protruded from between the teeth. 
Bleedings from the jugular vein, arm, and foot were performed without relief, 
but a rapid cure followed three deep incisions along the dorsum, extending 
from base to apex. The patient could speak in an hour after the incisions 
were made. In another case, that occurred in 1744, rapid swelling of one side 
of the tongue took place in a woman ; respiration was obstructed, and deglu- 
tition impossible. It was cured by one long, deep incision. Louis mentions 
a case that occurred in the military hospital at Metz in the year 1740. The 
tongue became spontaneously swollen. Alexander Benedictus, who published 
the case, mentioned that M. Casteras, the senior physician of the hospital, 
directed him to scarify the tongue lightly. This, however, was not sufficient, 
and the patient died in two days in consequence of the swelling. As Louis 
truly observes, life might have been saved by a couple of deep incisions along 
the dorsum of the tongue." 



782 ORAL DISEASES AND SURGERY. 

yet control is not secured, let ten, twenty, or thirty American 
leeches, or a third of the number of Swedish, be placed beneath the 
jaw. If the action is still unconquered, blood pro re nata is to be 
taken from the arm, and the tongue itself is to be freely incised. If 
yet the swelling goes on, and suffocation be threatened, laryngotomy 
or tracheotomy becomes a necessity. (See these operations.)* 

* " Mr. J. Z. Laurence exhibited before the Xorth London Medical Society 
the tongue of a woman who had died of acute inflammation of the organ. 
She had been under Mr. Laurence's care for acute rheumatism, when, on the 
evening of the 5th November, he was called to her, and found her sitting up in 
the bed, with a countenance expressive of the greatest anxiety, her face pale 
and bedewed with sweat ; she breathed at long intervals, and laboriously ; pulse 
130. The cause of this was evident ; she could not open her mouth to speak, 
for a swelling of the left half of the tongue, which was red, dry. and glassy. 
On the night of the 2d and 3d she had had severe rigors. Mr. Laurence at 
once made three free incisions into the tongue, and about half a pint of blood 
escaped. About two hours after the bleeding had ceased, the submaxillary 
region began to swell, twelve leeches were applied, and on the following 
morning the 7^/*?! half of the tongue began to swell, and by the afternoon it 
had attained full as great a size as the left. "With this was a corresponding 
engorgement of the tissues about the jaw: the local depletion had had very 
little effect in reducing the swelling of the left side of the tongue; generally 
she was worse ; rigors now came on, and the pulse intermitted three or four 
beats. Mr. Quain saw her. and proposed incising the right half of the 
tongue, but both patient and friends objected. Mr. Laurence saw her the 
last time alive the same night ; her surface was deadly cold ; pulse not percep- 
tible at the wrist, yet, strangely enough, the respiration went on tranquilly, 
though feebly. Mr. Laurence at once perceived that she was dying of slow 
asphyxia, and that her only chance was in tracheotomy ; this was proposed 
with more impressive force than a surgeon almost dare do. She and her 
husband doggedly refused. Xext morning she was dead. 

" Autopsy. — ~No organic disease was discoverable. The whole of the tongue 
was swollen, pale, and soft from maceration in a puro-serous fluid, which infil- 
trated the substance. The superior aperture of the larynx was greatly 
narrowed by serous effusion; the rirua glottidis to a less extent; below this 
point the whole of the trachea was perfectly unobstructed ; the submaxillary 
region and anterior triangles of the neck were infiltrated with a serous fluid, 
which, among the suprahyoid muscles, had assumed a purulent aspect. The 
lungs were singularly healthy ; the heart, kidneys, and bladder presented no 
signs of disease. 

" From the above facts, it follows that tracheotomy would in all probability 
have saved the woman's life; and Mr. Laurence believes he proposed it at the 
proper time. It is true there was, throughout the case, not one fit of suffoca- 
tion. On the contrary, she died choked in the most gradual conceivable 
manner ; and were he to meet with another case, he would not defer the 
operation until the patient was in his last gasp, as was too commonly the 



THE TONGUE AND ITS DISEASES. 783 

Abscess. — In depraved and tainted conditions of the system, 
abscesses, of what might be called a cold character, occasionally 
form among the deeper muscles of the tongue; such abscesses are 
not necessarily associated with any marked inflammatory phe- 
nomena, but may have attention first directed toward them by the 
swelling which appears on the under surface. 

The proper treatment in these cases will be found in voiding the 
matter through puncture as soon as fluctuation is perceived ; other- 
wise it has happened that the pus has dissected its way down the 
neck, pointing in front of the hyoid bone, creating much derange- 
ment, and threatening even a fatal result. Treat these cases by 
local stimulating injections and the internal administration of tonic 
medicines. Acute abscess is one of the terminations of glossitis. 
(See foot-note for illustration.)* 

case, but resort to it as soon as he saw the patient sinking, previous measures 
not having ameliorated his condition. A curious pathological fact, which 
Mr. Laurence noticed and pointed out to Mr. Phillips, who attended the case 
with him, was the successive and separate invasion of the two halves of the 
tongue by the inflammatory action, offering a remarkable instance of the 
dependence of pathological changes on the anatomical distribution of the 
blood-vessels." 

* The following suggestive case of abscess of the tongue, ending fatally 
from hemorrhage, is related by Mr. Ward, being presented before the London 
Medical Society : 

" E. T., aged seven, was born with a slight red enlargement in the centre 
of the tongue. No inconvenience or difficulty in the ordinary motions of the 
tongue, or in swallowing, had ever been experienced; the general health had 
always been good. In the night of Sept. 27, having been in her usual 
health at bedtime, she was attacked with pain and swelling under the chin 
and both sides of the lower jaw; slept very little, and the following morning 
had pain in the tongue, with great difficulty in speaking, or swallowing any- 
thing but liquids. She had an aperient powder at night, and the lower jaw 
was fomented frequently. In this state she continued for two or three days, 
and was visited by me on Oct. 1, when the following appearances were 
noted : — Face flushed ; eyes very bright ; countenance anxious ; great swelling, 
redness, and extreme tenderness of the parts under the lower jaw; very slight 
swelling of the tongue itself, which is covered with a thick, brown fur ; is 
unable to open the mouth wide, or move the tongue beyond the teeth, or to 
speak, and has great pain in the mouth ; pulse very quick and sharp; great 
heat of skin, and thirst urgent; bowels confined. Ordered eight leeches to 
be applied under the chin ; to take, at bedtime, four grains of calomel ; 
James's powder and sugar, of each three grains; a saline mixture, containing 
a scruple of nitrate of potash; one tablespoonful every three or four hours. 

" Oct. 2. Slept more last night than since first attacked ; fever great ; pain 



784 ORAL DISEASES AND SURGERY. 

Neuralgia of the Tongue. — The only neuralgia of the tongue 
which seems special and peculiar to the organ has its seat about the 

slightly relieved; swelling and redness less; mouth nearly closed ; was able 
to swallow the powder in jelly, but refuses the mixture, of which very little 
has been taken; bowels freely relieved, evacuations dark and offensive; to 
take calomel and James's powder, of each three grains, and jalap, five grains, 
at bedtime ; use a chloride-of-soda gargle, warm, to the mouth, by means of 
a syringe. Fluids taken in the mouth return by the nose. 

" 4th. Less fever ; rests better at night ; difficulty in swallowing or speak- 
ing the same ; can open the mouth sufficiently to allow the tongue to be seen, 
which is nearly fixed, very little swollen, and still thickly coated; the breath 
extremely fetid ; external redness and swelling still considerable ; the tender- 
ness great; pulse soft, quick, and weak; the bowels act freely; was able to 
pass my finger into the mouth ; under each side of the tongue distinct fluctua- 
tion can be felt; while pressing on the left side the lining membrane gave 
way, and was followed by a profuse discharge of fetid pus, mixed with blood ; 
the point of the finger passed easily to the depth of the first joint, under the 
tongue, giving the sensation of a large pulp cavity ; the tongue not very 
tender, can be moved from side to side by means of a small teaspoon, but not 
voluntarily. Apply strong poppy fomentation frequently, and linseed poul- 
tice ; continue the chloride-of-soda gargle under the tongue, with the syringe, 
and take, of a mixture consisting of six grains of quinine, a teaspoonful every 
four hours ; give a little port wine and water frequently, and milk or thin 
arrowroot for drink. 

"6th. The pain less since the use of the poppy fomentatioH, generally 
sleeping for some hours after using it ; the discharge of pus and saliva very 
copious and offensive ; lies with the head on the left side to allow the free 
exit of the discharge, otherwise the mouth is constantly filled ; fever less, as 
also the swelling and tenderness ; redness gone ; great debility and considera- 
ble wasting of the body already ; can swallow fluid, and is eager for the wine ; 
very little quinine has been taken; bowels act twice a day; can open the 
mouth wider, but. is still unable to protrude the tongue, which is cleaner and 
moister ; on slightly raising it by the handle of a spoon, a large jagged open- 
ing may be seen on the left under side of the lower jaw, from which, by 
gentle pressure under the chin, a profuse discharge of thick pus wells up, of 
which I pressed out at least two ounces ; pulse soft and weak. Continue the 
external applications; apply the chloride-of-soda gargle frequently to the 
mouth and under the tongue, with the syringe ; take a mixture consisting of 
two ounces and a half of decoction of bark, syrup of orange-peel, and tincture 
of bark, of each two drachms, a fourth part three times a day; continue the 
wine, and give strong beef-tea and arrowroot frequently. 

"9th. Altogether improved; discharge less, but still fetid; takes fluid 
nourishment frequently, and the wine ; the general swelling and the tender- 
ness reduced ; more on the left side under the jaw than the right, and is un- 
able to protrude the tongue farther. Continue all the applications and the 
mixture. 



THE TONGUE AND ITS DISEASES. 785 

extreme tip; the pain, which is very irregular in its coming and 
going, is of the most acute character, seeming indeed as if the 

" 11th. Has not rested so well the last two nights, and has had more pain, 
particularly on the right side, which is more swollen and very tender, the 
left side being almost in its natural state ; the discharge has been profuse, but 
thinner ; the tongue is moist and clean ; not very tender, but less movable ; 
the opening under the left side of the tongue smaller ; fever returned ; has 
constant hacking cough; not able to swallow so well, or to speak so as to be 
understood. Apply six leeches under right side of lower jaw ; continue the 
fomentations and poultices ; also, bark mixture and port wine. 

" 12th. Has slept very little, from the frequent coughing, which tires her 
very much ; discharge from the mouth less and thinner, but still fetid ; emacia- 
tion extreme; has changed the position of lying to the right side ; left angle 
of the mouth drawn down ; the swelling and tenderness on the right side very 
much increased since yesterday ; feels soft ; is more prominent in the centre, 
and appears pointing here ; the finger in the mouth can detect very distinct 
fluctuation under the tongue, which is thickly coated and very tender; takes 
very little nourishment, only a teaspoonful at a time: prefers wine to other 
things. Continue the fomentations and poultices. 

" 13th. Has had a bad night ; is very irritable and feverish ; mouth nearly 
closed ; unable to examine the tongue ; the swelling about the same ; the 
right cheek and under side of the jaw of a dusky red color, and very shining ; 
so tender that she has again changed the position ; lying on the left side ; 
cough less ; pulse very small and weak ; takes scarcely anything ; discharge 
more copious, thicker, and slightly tinged with blood ; it now appears to come 
from the right side. In the evening, while coughing, a large gush of blood 
took place from the mouth, mixed with pus, and flowed freely for more than 
ten minutes. By applying ice internally and externally (which I had directed 
to be in readiness), the hemorrhage was arrested. A cold lotion was applied 
externally, and an alum gargle frequently to the mouth. 

"14th. Has slept very little; unable to lie down, from the constant dis- 
charge of fetid pus and saliva from the mouth ; the swelling of the right 
cheek and side of the jaw less ; very tender, of a dull, yellowish color ; able 
to open the mouth so as to examine the tongue, which does not appear en- 
larged ; no power of moving it herself; is thickly coated with a dark fur, 
and when pressed upon, a profuse discharge of thick pus fills the mouth im- 
mediately ; no return of the hemorrhage ; is very pale and faint; pulse very 
small and weak; has taken more nourishment since last night than for some 
days before, such as port wine, isinglass in milk, beef-tea, jelly, etc. Con- 
tinue the lotion and alum gargle to the mouth with a syringe. At half-past 
seven p.m., in the act of swallowing a small piece of bread-and-butter, profuse 
hemorrhage occurred from the mouth, and more than a pint of blood was lost 
before it was again arrested by the free application of ice ; it was of a bright 
arterial color. She became faint, and expired at nine p.m. 

"On the day following I made a post-mortem examination of the parts 
affected. The parotid, submaxillary glands, and other parts, having been 

49 



786 ORAL DISEASES AND SURGERY. 

organ might be in the grasp of red-hot pincers. This neuralgia, as I 
have met with it, has been in the persons of middle-aged men : of the 
cause of it I have no conception. Yanzetti, for the cure of such a 
neuralgia, has recommended and practiced the operation of section 
of the lingual nerve, — accomplished by first drawing the tongue 
forward and to one side, and exposing the nerve, through incision 
of the mucous membrane on the border of the internal pterygoid 
muscle. An excellent obtunder is found in the combination sug- 
gested in the paragraph on Epithelioma. Lingual neuralgia? origi- 
nating in the offense of jagged teeth have their cause too evident to 
need comment. 

Effusions. — The tongue is occasionally the seat of formidable 
congestions or effusions. I have known an inflamed tongue so 
swell in a single hour as almost to prevent respiration. The organ, 
when enlargement increases to an extent which threatens suffoca- 
tion, looks so vascular that one hesitates to use the knife. I am 
sure, however, I suggest the very best practice when I say incise 
freely, — cut deeply from behind forward, on each side of the median 
line, avoiding, however, in the depth of the cut, the ranine arteries. 
A wound thus made will bleed for a time freely, even alarmingly; 
but the common experience is that such cuts soon close, and are 
devoid of danger. Velpeau has recommended the opening of the 
ranine veins in congestion. Leeches are also applied direct to the 
tongue. 

Erysipelas. — A formidable danger in the tongue is the presence 
of erysipelas : this may be idiopathic, but is most frequently' trau- 
matic, operations about the jaws being, occasionally, provocative of 
this condition. The treatment of erysipelas in the tongue is the same 
as its treatment elsewhere. Iron and quinia, internally and locally, 
should be freely employed. If this be not found effective, then make 

"brought into view, were found (on the right side) so much softened, decom- 
posed, and mixed with coagulated "blood and pus, as to be recognized with 
difficulty, and it was impossible to trace from what vessel the hemorrhage 
proceeded, such was the destruction of the parts. On the left side, the glands 
•were of a greenish color, very much softened, and bathed in pus. A probe 
passed readily by the side of the jaw into the mouth. I divided the trachea 
just above the sternum, and dissected the larynx and tongue carefully out. 
The morbid state of the tongue is shown in the preparation before the society." 
In the discussion w*hich ensued, the case was considered a very remarkable 
one. The remarks had reference chiefly to the cause of the disease, respecting 
which various opinions were expressed. 



THE TONGUE AND ITS DISEASES. 787 

incisions. The practitioner is, however, never to forget to extend 
his observations over any functional disturbances which may exist. 

Bites of Insects. — The most severe and threatening glossitis 
ever met with by the author was the result of the sting of a wasp 
taken into the mouth while eating blackberries. The tongue in these 
accidents is apt to swell enormously, but, happily, tends to a rapid 
self-cure. If seen immediately, no better application may be employed 
than the phenate of soda ; dilute ammonia is also a favorite prepara- 
tion : later, we can only treat such an inflammation like any other of 
the sthenic type. It is well, however, to remember that the swelling 
in these cases is from effusion rather than a congestion ; incisions, if 
necessary, may always be freely made. Iodine, in these instances, 
sometimes acts very happily; paint the tongue thoroughly, and hold 
cold water in the mouth. If, unfortunately, erysipelas should super- 
vene, the iron and quinia combination is at once to be resorted to.* 
In these cases the pain becomes excessive, the parts may assume 
a livid hue, and there seems to be a decided tendency to gangrene ; 
particularly does this occur in depraved and broken-down persons. 
Free incisions are never to be neglected : the degraded expression of 
the erysipelas in these cases depends upon the separation of the 
molecules — if the expression may be used — from their base of sup- 
ply ; the incisions, draining the organ, allow contraction of the parts, 
and thus restore the circulatory relationship. 

In ulcers or tumefactions of the tongue provoked by irritating 
teeth, it is seldom necessary to do more than remove the source of 
offense. Cases occur, however, where some after-treatment is de- 
manded, the provoked ulcer being indolent, or, in some instances, 
even semi-gangrenous. For all such sores, the best wash that I have 
ever used is water, changed in color to a milky blue by the addition 
of the compound tincture of capsicum. Where a part is simply 
indurated and not ulcerated, presenting no evident cause, it is better, 
for a time at least, to leave the case to nature. My own rule is, 
never to meddle with a non-explainable induration except from ne- 
cessity. In all these cases injudicious meddling will be found very 
bad practice. 

Erectile Tumors. — Of this character of lingual tumors the author 

* R. — Tincturse ferri chloridi, 31J ; 
Quiniae sulphatis, gr. xv ; 
Tincturse cinchonas, gij to ^ss. M. 
The author believes that this combination, as a local application, is an ap- 
proach to a specific in erysipelas. 



788 ORAL DISEASES AND SURGERY. 

has met thus far with some five cases. Of these, the most marked 
was in the person of a babe nine months of age, for whose relief an 
operation was successfully performed at the University clinic. This 
tumor, which was congenital, occupied the whole anterior third of 
the tongue, protruded from and filled up the oral fissure to a consid- 
erable extent, was of a dark red or purple color, enlarged very 
much when the child cried, was soft and fluctuating, and through 
manipulation could be made temporarily to disappear. 

A mode of operation which in two weeks resulted in a perfect 
cure, consisted in first strangulating the mass with a double ligature, 
and, after three days, effecting separation through the instrumen- 
tality of a wire ecraseur. 

The principle of the treatment of erectile tumors of the tongue is 
the common principle applicable to this class of tumors wherever 
found. (See Erectile Tumors.) 

Fatty Tumors. — These, like the erectile, are uncommon. A case 
which I once saw exhibited the tumor looking like a mass of very 
smooth fat, encysted by the mucous membrane: the situation was 
the inferior left surface of the organ. As the patient would speak, 
the tumor would bulge out over his lower teeth, presenting a most 
unsightly appearance. He was not willing to submit to an opera- 
tion ; and it was with a feeling of disappointment that I found my- 
self unable to follow the history of the case. 

Metastatic Disease. — An example herewith given explains, 
without other remarks, a character of trouble rare, yet sometimes 
met with, upon the tongue. We may recognize in the disappearance 
and reappearance of the various exanthems an explanation of the 
condition. "I have been consulted," says Mr. Wm. McClure, in a 
paper read before the Harveian Society, "by a youug married lady, 
for rather a curious affection. She informs me that her tongue 
becomes occasionally bestudded with small ulcerations, and, after- 
ward, when these get well, the palm of her left hand becomes affected 
with a sort of psoriasis palmaris. The tongue is at present quite 
well, but the palm of her hand is covered with the eruption. When 
this gets better, however, she expects her tongue to become again 
the seat of disease, for thus they have alternated for a considerable 
time past, — she says about two years. The chief reason for which 
she consults me at present, however, is that she has gout in one of 
her feet. I believe that the whole series of her complaints depends 
on some derangement of the digestive organs, though that is not 
made very apparent by external symptoms. I gave her an alterative 



THE TONGUE AND ITS DISEASES. 789 

pill, and a tonic mixture, combined with colchicum and an alkali. 
The gout has already disappeared, and even the hand is much im- 
proved. As soon as the gout was got rid of, I substituted for the 
tonic mixture — in which, as I have just said, were wine of colchicum 
and carbonate of soda — a mixture composed of the extract of sarsa- 
parilla combined with the iodide of potassium. As a local applica- 
tion to her hand I prescribed an ointment composed of pure iodine, 
iodide of potassium, and hog's lard; but this was found, upon trial, 
to give her so much pain, and produced so much irritation, that I 
was forced to abandon its use after a few days' trial. For it I sub- 
stituted the following ointment, viz. : white oxide of mercury four 
grains, and extract of conium a drachm, rubbed up with seven 
drachms of prepared hog's lard. This ointment was ordered to be 
rubbed into the palm of her hand every day, both morning and 
evening. Besides these remedies, local and general, she took occa- 
sionally an alterative and aperient pill, made up of blue pill and the 
compouud extract of colocynth. The consequence has been, after a 
month's steady use of the remedies, that the hand has become quite 
well, the skin being now, for the first time these two years, soft, 
white, flexible, smooth, and completely free from itching, heat, and 
every unpleasant appearance and feeling. Nor has the tongue as 
yet shown any tendency to alternate disease, as before ; so that we 
have reason to hope — the constitution having been set to rights by 
the means employed — the former chain of morbid sympathy between 
the distant organs of which we have been speaking, and by which 
a metastasis of the psoriasis, from the one to the other alternately, 
took place so often, for so long a time, has been at last broken and 
destroyed, permitting both to remain in their healthy condition." 

Urticaria, a very common skin-trouble, I have myself met with 
as having a similar metastatic relation. In this case a wheal would 
appear either upon the cheek or the tongue whenever ice-cream was 
eaten. 

Hypertrophy. — This condition has been met with and described 
by various writers.* Hypertrophy may be complete, involving the 

* " A case is related by Zacchias, of a male infant well made except that the 
tongue projected three fingers' breadth from the mouth : the child could suck, 
and lived until the age of fourteen months. Bertholin mentions a case of 
linguae portentosa magnitudo, where a male child was horn with the tongue 
out of its mouth as large as a filbert : as the child grew its tongue enlarged 
to the size of a calf's heart. A case is recorded by Dr. Humphrey of a child, 
eleven years of age, whose tongue from the upper lip to its tip measured 






790 ORAL DISEASES AND SURGERY. 

whole organ, or the enlargement may pertain to particular tissues 
alone. A case is described by Mr. Paget, involving the muscular 
substances exclusively, the primitive fasciculi being found to divide 
in a dichotomous manner. The epithelium is another of the tissues 
most frequently found affected, instances being on record where this 
structure has thickened so as to resemble a coat of mail. Granular 
hypertrophy, a condition of enlargement of the papillary structure, 
is sometimes seen in the form of a mass of warty excrescences cover- 
ing the whole body of the tongue ; at other times it is confined to 
some portions more or less limited in extent. 

The treatment of a hypertrophied tongue must be governed by 
the circumstances and character of each particular case. In epithe- 
lial hypertrophy the best results seem to have been secured through 
the use of arsenic, — from the thirtieth to the twentieth of a grain 
being administered three times a day, its effect being carefully noted. 
Donovan's solution, the liquor arsenici et hydrargyri hydriodatis, 
given in five-drop doses, has been highly commended ; also the solu- 
tion of Lugol. 

In granular or papillary hypertrophy, the use of chromic acid will 
be found desirable, the various excrescences being touched daily with 
the crystals. Another excellent application is the solution of the 
perchloride of iron. Cutting the warts away in mass, by the use 
of a pair of scissors, may be practiced where the parts are not too 
vascular. Pyroligneous acid is another favorite means of care. 

In a true hypertrophy of the organ — prolapsus, as it is frequently 
miscalled — that is, where the body has enlarged as a result of con- 
genital impressions, medicinal appliances are of little service. This 
disease is markedly one of young life, commencing generally very 
soon after birth, and progressing tardily but surely until death or 
an operation may give relief. Unaccountable though it may seem, 
hypertrophy is confined almost exclusively to female children, — this 
sex being affected in the proportion of five to one. 

As may be inferred, hypertrophy of the tongue presents various 
degrees of enlargement, cases being on record where the organ has 
hung from the mouth, resting upon the breast. In the cases of ele- 



three and a half inches ; from the under lip to its tip, one and a half inches ; 
from the angle of the mouth round the sides and tip to the opposite angle, 
six and a half inches. The circumference of the widest part, which was about 
the middle of the protruded portion, measured six and a half inches circular 
measurement. ' ' — Holmes. 



THE TONGUE AND ITS DISEASES. 791 

phantiasis, the mucous membrane looks more like the bark of a tree 
than anything else, being' rough, dry, and crusted. 

In the treatment of hypertrophy we consider the character of the 
trouble from the aspects of activity and chronicity. Where the first 
of these characters exists, most may be hoped for from medication ; 
where the latter obtains, little may be expected except from operation. 

Compression, recommended by Lasser and indorsed by Professor 
Syme, it may not be amiss to try before proceeding to excision ; 
but the treatment will certainly be found to have much more of 
failure than of success in it. The author lately had at his clinic a 
boy in whom congenital hypertrophy had enlarged one side of the 
tongue to a bulk fully double that of the other. 

As the opposite to hypertrophy, reference may be made to a 
condition sometimes, though unfrequently, met with, of atrophy. A 
case described by Dupuytren found its explanation in a post-mortem, 
which revealed the presence of hydatids at the base of the cerebellum ; 
one of which, wedging itself into the anterior condyloid foramen, had 
compressed the lingual nerve and thus obliterated its function. 

Operations practiced upon the Tongue. — From surgical neces- 
sity, or from accident, it sometimes becomes necessary to amputate 
a part or even the whole of the tongue. Surprising as it may seem, 
such amputations, even when of the complete organ, interfere very 
little with the speech, and do not entirely obliterate the sense of 
taste. Mr. Nunneley, an English surgeon, lately exhibited to the 
Pathological Society of London a patient from whom he had re- 
moved the whole of the organ, this being effected by a submental 
opening, the patient, a man aged thirty-five, never having a bad 
symptom. The disease, which had existed sixteen or eighteen 
months, became worse two months before the operation, and, from 
the pain and difficulty of speaking, the impossibility of mastication, 
and difficulty of deglutition, was fast wearing the patient out. When 
shown to the society, the patient had recovered strength and flesh ; 
indeed, said that he felt as well as ever : he talked with great dis- 
tinctness, and swallowed with facility. 

A second interesting case is reported by the late James Syme, 
F.R.S.E., Surgeon-in-Ordinary to the Queen in Scotland, and Pro- 
fessor of Clinical Surgery in the University of Edinburgh. 

"About twelve months ago," says Mr. Syme, "I communicated 
a case in which the tongue had been completely removed by ex- 
cision, on account of extensive disease that threatened to prove 
fatal by preventing the admission of nourishment. This account 



792 ORAL DISEASES AND SURGERY. 

was necessarily limited to the operation and its immediate effects, 
as sufficient time had not elapsed for determining whether or not 
the relief afforded would prove permanent, or how far the powers 
of deglutition, articulation, and taste would be restored. After his 
return home to Manchester, the patient sent me favorable reports 
of his progress, but certainly not such as to convey any adequate 
idea of the improvement that had taken place since he came under 
my care. He was then emaciated and bent down by long-continued 
suffering, unable to articulate, so as to require a slate and pencil for 
expressing his wishes, and swallowing even fluids with such extreme 
difficulty as to feel on the point of starvation. My surprise may, 
therefore, be imagined when, on the 10th of September last, he un- 
expectedly made his appearance, erect and vigorous, and, seeing 
that I did not recognize him, announced his name in a loud, clear 
voice. The feeling thus excited was not lessened by learning that, 
while traveling in the Highlands, he had dined at tables-cVhote and 
entered into conversation without betraying the deficiency under 
which he labored. Yery much astonished by a result so much 
better than could have been anticipated, I requested a number of 
my medical friends to join me in examining the state of matters. 
Professor Goodsir and Mr. Nasmyth having satisfied themselves 
that no vestige of the tongue remained, various observations were 
made with regard to articulation and other functions of the absent 
organ; and Mr. Annanclale afterward instituted a more particular 
inquiry, of which he has given me the following report: 

" ' The lips and jaw-bone, where divided, were soundly united 
without any deformity. The opening between the mouth and pharynx 
was much diminished in size and irregular in shape from contraction 
of the fauces and soft palate, which were drawn downward and 
forward more to the right than the left side, from the mucous mem- 
brane at that part having participated in the disease and been 
removed along with the tongue. Mr. W. says that he can swallow 
as well as ever, provided that the food is either finely divided or 
fluid. He is also able to masticate solid substances, although diffi- 
culty is sometimes experienced from their getting into awkward 
parts of the mouth. In ordinary speech his words are wonderfully 
clear and distinct, and he can sing without any difficulty. All the 
vowels and words composed of them are articulated perfectly, and 
also the following consonants : B, C, F, H, K, L, M, N, P, Q, R, 
Y, W. D is pronounced " dthe," J " the," G like " sjee," " S" is a 
lisp. His taste is impaired, but still enables him to distinguish 



THE TONGUE AND ITS DISEASES. 793 

different articles and their respective qualities, as grouse from par- 
tridge, bitters from sweets, good beer from bad beer, etc. He has 
remarked that the seat of sensation lies somewhere in the throat, 
since there is no recognition of taste previous to the act of swallow- 
ing ; and, in order to ascertain the truth on this point more pre- 
cisely, the following experiments were made : 

" ' 1. A strong solution of salt was applied by means of a camel's-hair 
brush to the fauces, palate, floor of the mouth, lips, and inner surface 
of the cheek, with the result of something being felt in the mouth, 
but no idea formed as to its nature. 

" ' 2. About a quarter of a teaspoonful of finely-powdered sugar 
was placed on the floor of the mouth, and, having been allowed to 
remain there a few seconds, was then brought thoroughly into con- 
tact with every part of the cavity without any recognition of its 
nature ; but when a little water was added and swallowed, the taste 
was immediately perceived. 

" ' 3. The same experiment was repeated with another substance 
(salt), and with the same result.' 

" It has long been known that large portions of the tongue may 
be removed without destroying or materially impairing the power 
of articulation ; but I am not aware of any case on record in which 
it has remained so perfect after complete removal of the organ.* Of 



* Complete extirpation of the tongue has now been practiced with success 
by a number of surgeons, among them by Fiddes, Heath, Nunneley, Annan- 
dale, Kizzoli, and Sedillot. 

Excision of Tongue. — "The removal of the entire tongue is altogether a 
modern surgical operation. Though, for time out of mind, greater or less 
portions of the tongue have been removed by cutting instruments, escharotics, 
actual cautery, or ligatures, the importance of the organ in deglutition and 
articulation, the difficulty of reaching its base, and especially the fear of not 
being able to arrest the hemorrhage, owing to the depth of the wound, the 
size of the arteries, and their near origin from the carotids, have not un- 
reasonably deterred attempts at more than partial amputation of it. I believe 
it was Mr. Syme who first suggested an operation for its entire removal, and 
performed it in the presence of many members of the association, when its 
meeting was held in Edinburgh. Unfortunately, that patient, as well as a 
second, died a few days after the operation; and a solemn warning was pub- 
lished by Mr. Syme, who declared that the operation was so serious that 
further attempts were not justifiable, as ho one could recover from it. Subse- 
quently, I believe, in a third case, Mr. Syme was, by a like proceeding, re- 
warded with success; and Mr. Fiddes, in Jamaica, and Dr. G. Buchanan, 
in Glasgow, have also succeeded by the plan laid down by Mr. Syme. How- 



794 ORAL DISEASES AND SURGERY. 

the facts above mentioned, the one that seems most curious is the 
connection between taste and deglutition ; from which it appears 
that the latter is essential for the full perception of the former. If 
the pleasure of taste could be perfectly gratified by mastication 
without deglutition, there would be no limit to the consumption of 
food ; but the instinctive desire to swallow an agreeable morsel 
affords a check to any such abuse." 

Mr. Paget reports the following case : 

" On the 20th of February a little girl, about three years of age, 
was brought into the operating theatre of St. Bartholomew's Hos- 
pital with hypertrophy and prolapsus of the tongue, which com- 
menced when she was some six months old. It now protruded 
nearly two inches, and hung downward, completely filling the circle 
of the lips ; its end was dry, and excoriated with hardened epithe- 
lium, a sort of crust having formed of the size of a shilling ; several 
of the papillse also were enlarged, and in places gave to the tongue 
a warty or granular appearance. The lower jaw had already begun 
to be deformed, and expanded downward and outward; the teeth 
were gradually separating from one another in the mental portion 
of the jaw, and there was dripping of saliva. An examination of 
the tongue by Mr. Paget showed that the organ was truly hyper- 
trophied, and the part not prolapsed completely filled the cavity' of 
the mouth. 

" Chloroform was carefully given to the child, and the chain of an 
ecraseur was passed around the tongue within the mouth, the jaws 
being kept open by a metal gag. The chain was slowly drawn 
home, and the prolapsed and hypertrophied portion was detached 
with little or no bleeding. 

ever, "believing that the severity of the operation depended far more upon the 
method of proceeding than upon the mere removal of the tongue itself, I 
devised what I hoped would prove to be a less formidable one, and which 
experience has proved to be so. Up to the present time I have removed the 
entire tongue nineteen times, and Dr. Fenwick, of Montreal, has done the 
same operation once, without any untoward symptom following in a single 
instance. In mdit cases the patient has not required any after-treatment, 
being able to sit up the following day, and in ten days to he considered well. 
In the majority of operations not a drachm of blood has been lost. In two 
cases only has there been any hemorrhage, and in those not more than half 
an ounce of blood was lost. In one a point of hot wire, and in the other a 
ligature, at once arrested the bleeding. The little constitutional disturbance 
which follows this operation is surprising : indeed, in the majority of cases 
there is none." — Thomas Nunneley, F.R.C.S. 



XII 










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J> - *k 





/■ M 



■\" 



THE TONGUE AND ITS DISEASES. 795 

" On examination of the piece removed, its structure was found to 
be similar to that of the natural organ, both in texture and color: it 
was simply a redundancy of growth from hypertrophy. 

"The subsequent progress of the case was reported as most satis- 
factory, a good recovery being recorded." 

Partial amputations of the tongue have been very frequent. Union, 
in many of the cases, is very rapid and perfect. In one case, that of 
a child, where a kind of a flap operation was made, I got reliable 
union in a single day, and had no trouble with the case afterward. 

Amputation of the tongue, complete or partial, is practiced wkh 
ligature, knife, and ecraseur. The author, from his own experience, 
gives the preference to the last means. 

Operations. — For a surgical study of the tongue, and the opera- 
tions practiced upon the organ, the reader will turn to Plate XII. 

Subfig. 1, in plate, is a front view of the anatomical relations of 
the parts about the fauces, as shown with the mouth wide open. 
1, the dorsum of the tongue ; 2, 3, the tonsils; 4, the uvula ; 5, the 
anterior half arch ; 6, the posterior half arch, with the tonsil between 
it and 5 ; T, the soft palate. 

Subfig. 2 represents a side view of a vertical section of the mouth 
and tongue, showing the relations of the vessels and nerves of the 
tongue. 1, the lingual artery; 2, its sublingual branch, — the veins 
accompanying the arteries ; 3, the hypoglossal nerve ; 4, the ranine 
terminations of the lingual vessels. 

Subfig. 3 represents the situation and associations of a disease 
compelling amputation of a section of the tongue. The lines, 1, 2, 
3, form a Y, which is to circumscribe the growth ; it should, how- 
ever, have been placed much farther back. 

Subfig. 4 exhibits the operation of excising the tongue, as prac- 
ticed with scissors. When the knife is used, the sections are 
similarly made. If, in such an operation, the hemorrhage is threat- 
ening, it is better to ligate quickly the vessels of one side before 
making the section of the other ; this suggestion, however, only 
holds good when the bleeding orifices are freely exposed and can 
be reached without effort or difficulty. 

Subfig. 5 shows the preceding operation completed, and the flaps 
united by ligatures. 1, 2, represent the sutures : wire pins or 
waxed silk may be used. Let them be left in only long enough to 
secure the union ; this, if no undue inflammation supervenes, will 
be accomplished in from twenty-four to forty-eight hours. 



796 ORAL DISEASES AND SURGERY. 

Subfig. 6 is the lingua vitula, or lingual hypertrophy. The par- 
ticular case here represented was a patient of Dr. Harris, of Phila- 
delphia, and was the first operation performed in the United States. 
The case is thus described by Prof. Smith in his System of Surgery : 

" The patient, aged nineteen, had the tongue enlarged at birth. 
A short time previous to the operation it projected beyond the upper 
incisors at least three inches. Its circumference was six inches, and 
its vertical thickness one inch and a half; it filled up the jaws so 
completely that it was necessary to have his food cut into small 
pieces and introduced at the side of the tongue." 

The operation practiced by Dr. Harris was accomplished as fol- 
lows : " The tongue being elevated, a strong ligature was passed 
through its top so as to control its movements. The under surface 
was then dissected from the floor of the mouth about three-fourths 
of an inch behind the anterior part of the jaw, and a strong, straight 
bistoury introduced into the organ at a point where the dissection 
terminated, whence it was pushed through between the median line 
and the left ranine artery, and, being drawn laterally and forward, 
was made to cut a flap, which terminated near the first bicuspid 
tooth. The left ranine artery being then secured with a ligature, 
the bistoury was again introduced in a corresponding position on 
the right side, and the opposite, or right flap, made in a similar 
manner. The artery of this side being now secured, and the space 
intervening, or central portion, divided by strong scissors, the in- 
cisions or flaps resembled the letter V, and, being approximated by 
these interrupted sutures, made a pointed, well-formed tongue of 
the ordinary length. A year subsequently the patient articulated 
distinctly, and was relieved of all deformity." 

Pig. 243. — Amputation by Strangulation. 




In another case, somewhat similar to this, under the care of the 
same surgeon, a ligature was applied to the enlarged portion, in 



THE TONGUE AND ITS DISEASES. 797 

order to cause it to slough off; but the irritation, Prof. Smith informs 
us, was so great that Dr. Harris found himself subsequently com- 
pelled to amputate the end of the tongue with a catlin. In this 
patient the organ protruded four inches ; its circumference was over 
six inches, and its vertical thickness nearly two inches. 

Fig. 243 represents a condition of resisting ulcer (met with quite 
frequently by every practicing surgeon), together with a manner of 
treatment by strangulation. With such ulcers and such manner of 
treatment the author has had quite a large experience, but, as before 

remarked, he drives the preference to the ecraseur. 

Fig 244 
A mode of using the ligature, more convenient 

than that exhibited in the diagram, and quite 
as effectual, consists in the passage of the 
double thread, exactly as is represented in this 
case by the threads occupying the middle posi- 
tion; separating this double ligature, it may be 
made to circumscribe any portion of the tongue 
simply by the passage of pins: as, for example, 
if in the places of the first and second threads, 
as shown, pins were placed, it must be seen that, 
by separating the double middle ligatures and 
casting them back of the pins, the part included 
would be precisely the same as found here with 
the six ligatures. By such use of the double ligatures the author 
has amputated full half the tongue twice within four months. Such 
a mode of employing the double ligature, not alone for the tongue, 
but in any other situation, is shown in Fig. 244. 

The Ecraseur. — Fig. 245 exhibits the ecraseur of the inventor 
of the instrument, the French surgeon M. Chassaignac. Of the 
two forms shown, the one to the right will be found most to com- 
mend itself, the direction of the chain being best controlled by it. 
To use the ecraseur, it is simply necessary to arrange the chain back 
of the part to be amputated, the handle being next slowly turned, 
whereupon the chain, little by little, is retracted, until finally— the 
time should seldom be less than half an hour — the portion of tissue 
drops off, without, quite as likely as not, the loss of a single drop 
of blood ; as exhibited in the case of an amputation of the tongue, 
performed at a recent clinic by the author before his class, where 
the operation was strictly devoid of hemorrhage. 

As a substitute for the chain of the Chassaignac instrument, a 
common annealed wire is used by many with the most complete 




798 



ORAL DISEASES AND SURGERY. 



success. The use of such a wire is highly commended by M. Maison- 
neuve, of Paris, who has published a memoir on what he terms the 



Fig. 245. — Chassaigxac's Ecraseur. 



Fig. 246. 





"ligature extemporanee." Fig. 246 exhibits this ecraseur, and the 
mode of its application. A screw like that of Graefe's serre-nceud, 
or any other convenient means, may be employed to tighten the 
wire. A very convenient instrument of such character is furnished 
at a trifling price by Mr. Kolbe, of Philadelphia, and may be procured 
of most surgical cutlers. With such form of ecraseur, the author 
has succeeded in amputating without trouble fully two-thirds of the 



Amputation of the tongue in full, an operation now attracting 
considerable attention, is variously practiced. A mode known as 
that of Kegnoli, shown in Fig. 247, consists in opening into the 
oral cavity from the neck, and, by means of a loop in the tip, drawing 
the organ downward. To open into the cavity by this plan, the 
operator commences by.making a curvilinear incision corresponding 
to the arch of the jaw, extending nearly from angle to angle. Joining 
this first incision is a second of vertical direction, extending to the 



THE TONGUE AND ITS DISEASES. 



799 



hyoid bone. The flaps are next to be reflected, and, after incising the 
lingual muscles from the bone, the tongue is caught by the tip and 
drawn out of the mouth. Complete control of the organ being thus 
secured, the knife or ecraseur is employed to make the separation. 



Fig. 247. — Kegnoli's Operation. 



Pig. 248. — Syme's Operation. 




.A second manner of operation is that which was practiced by Mr. 
Syme. This is shown in Fig. 248, and is as follows. A first inci- 
sion di.vides the lower lip in its exact median line, being carried down 
to the hyoid bone. Next the bone, by means of a saw, is separated 
at the symphysis; this may or may not necessitate the removal of 
the two front teeth. Placing the finger as a guide beneath the 
tongue, the surgeon next incises the mucous membrane, together 
with the muscular attachments. At this stage attention may be 
given to the hemorrhage, or the tongue, as shown, may be drawn 
forward and the amputation completed by the ecraseur. 

Statistics favor the Regnoli operation rather than that of Mr. 
Syme, the section of the jaw in the latter complicating to a marked 
extent the process of cure. 

Still another operation, practiced by Mr. Nunneley, of Leeds, 
has yielded a success most satisfactory, since of nineteen cases in 
which this surgeon has operated, removing the whole or. a large por- 
tion of the tongue, every one resulted in recovery. The operation, 
as practiced by Mr. Nunneley, consists in a slight incision, a punc- 
ture, indeed, made in the exact middle line of the throat, — a little 
nearer the base of the jaw than the hyoid bone, the bistoury being 
passed upward until it emerges at the fra3num ; through this wound 



800 ORAL DISEASES AND SURGERY. 

is now drawn up the chain of the ecraseur, the loop being cast about 
the base of the tongue. Next, with a volsella, or by any other con- 
venient means, the organ is pulled outward and upward. To control 
and secure the loop of the chain about the base, two strong curved 
pins are passed from below, through the tongue, to the base ; the 
loop thus controlled, the ablation is made as in the previous cases. 

A fourth process is that practiced by Mr. Paget. Separating 
first the general attachments of the genio-hyo-glossal muscles, this 
surgeon dissects along the floor of the mouth, thus liberating the 
tongue, whereupon the organ is caught, drawn forward, and removed 
with the ecraseur. 

In limited ablations, the surgeon, not having at command the 
ecraseur, may use with satisfaction the ligature as described a page 
'back. A point of importance, however, to consider in the use of 
this means, is the danger of cutting the ligature out ; it is really a nice 
point to draw tight enough, yet not too tight. I have seen a ligature 
cut through a tongue almost with the facility of a knife, compli- 
cating matters most seriously by the hemorrhage which followed. 
Another matter is correspondence in size of the ligature with the 
needle used. A needle, larger than the thread which is to occupy 
the line of its passage, will not unfrequently have its use associated 
with an oozing of blood, so persistent as to compel the repetition of 
an operation. 

In the use of the ecraseur the surgeon will also not unfrequently 
find himself confronted by hemorrhage, and particularly may such a 
result be anticipated where abundance of time has not been allowed 
for the ablation : the rule with this instrument should be, " never 
make haste." 

Shock, inflammatory perversions, and septaeinia, are the dangers 
associated with operations upon the tongue, and which the prudent 
surgeon will guard against by every precaution known to the 
science. After an operation of magnitude upon this organ, I believe 
it is always prophylactic practice to prescribe veratrum viride, 
bromide of potassium, and morphia; while as a local detergent, 
nothing better can be used than the phenate of soda, or, if inflam- 
mation supervenes, this conjoined with the fluid extract of hamamelis 
Yirginicus. 

Tongue-Tie. — The condition denominated tongue-tie is frequently 
met with in young children, and, indeed, occasionally in the adult. 
Tongue-tie is simply a shortening or curtailment of the anterior 



THE TONGUE AND ITS DISEASES. 801 

mucous fraenum. A tongue that cannot be projected beyond the 
teeth, and in the attempt at projection has its tip drawn downward, 
is tied, and a tongue so tied cannot perform its various offices com- 
fortably and naturally. Upon examining the mouth of a child thus 
afflicted, the tip of the tongue will not unfrequently be found fixed 
to the floor of the mouth, incapable, indeed, of any movement. 
These, however, are extreme cases, the usual condition being simply 
curtailment of natural motion. 

Tongue-tie is of two kinds, adventitious and congenital. Of the 
first, that arising from ulceration is the most common. A person 
having a bad ulcer under the tongue, particularly if on the side of 
the fraenum, is almost sure to have this fold shortened as the result 
of cicatrization. 

A second expression of this first form is one described by Prof. 
Dewees, exceedingly rare, I imagine, but worthy of note. 

"There is found attached," ^ays Dr. Dewees, "to the fraenuni of 
the tongues of new-born children a nearly transparent, whitish 
membrane, which pursues the natural fraenum through its whole 
course, continues beyond the point where the fraenum stops, and 
terminates near the extremity of the tongue itself; so that the tongue 
is tied down, as it were, to its proper bed. 

"In consequence of this disposition of the fraenum, the child 
cannot elevate the tongue or protrude it beyond the lips, and in 
attempts to suck cannot apply it with sufficient force or certainty 
to the nipple to make a complete exhaustion; therefore it sucks 
but imperfectly; and this is accompanied by a clucking kind of 
noise. Whenever this is observed, the mouth should be examined, 
and it will almost always be found in the situation just described ; 
but not necessarily, as there may be clucking without this mem- 
brane ; but this membrane, we believe, is never without the clucking. 

"This membrane is easily discovered by provoking the child to 
cry, or by elevating the point of the tongue by the extremity of the 
little finger. In making the attempt to raise the tongue, the child 
is almost sure to cry ; and then this membrane is readily discovered, 
as it is now fully upon the stretch. 

" This defect is easily remedied. It should be done in the follow- 
ing manner. Let the child be laid across the lap of the nurse, with 
its face toward a proper light, and the operator stand behind the 
head, so that he does not intercept the light. The chin of the child 
must be gently depressed by the forefinger of the nurse. When the 
chin is thus depressed, the little finger of the left hand of the oper- 

50 



802 ORAL DISEASES AXJD SURGERY. 

ator must be insinuated between the side of the tongue, near its tip, 
and the inner corresponding portion of the jaw, until it can lift up 
the point of the tongue ; which being done, the membrane is imme- 
diately brought into view, and upon the stretch ; or, should the child 
now begin to cry, as it almost always does, the operator can easily 
place his finger under the tongue, and keep this false fraenuin tense, 
while, by a single stroke directly across it by a sharp gum lancet, 
he divides it to the true frsenum : the operation is then finished. 
We have never known it necessary to repeat this operation. The 
incision through the membrane never yields more than a small drop 
of blood ; no hemorrhage can ensue, as this tissue is but very slightly 
vascular." 

A third of the adventitious forms, occurring in the adult, is the 
result of induration of the frsenuni. This is occasionally vene- 
real in character, or it may be cancerous. In these cases the 
band gradually thickens until the motion of the tongue is markedly 
impaired. The cancerous is distinguished in its incipiency from 
the venereal disease by the greater pain associated with the move- 
ments of the parts : in the first, the pain is acute and sharp ; in the 
second, it is soreness rather than pain. If the induration is malig- 
nant, the parts may be excised, but the hope of cure is very slight ; 
if venereal, we pursue the specific treatment conjoined with such 
general and local combinations as may seem demanded by the 
circumstances of the case. Donovan's solution, given in five-drop 
doses, is quite reliable. The practitioner is to avoid over-irritation 
of the fraenum. 

Congenital tongue-tie is quickly appreciated by lifting the tip of 
the organ. These cases differ very much, the frasuum, at times, 
being observed to run as in the normal course, except that it is much 
shortened. In other instances the fold passes forward almost to 
the apex. This fold may be free or tight. If the former, it forms a 
septum between the lateral aspects of the floor of the mouth, but is 
not otherwise inconvenient ; if the latter, it ties the tongue more or 
less closely. 

The relief of a congenital tie consists in nicking or cutting the 
contracted frsenum. This operation, although of the simplest nature, 
requires to be performed with some care. A frsenurn too freely cut 
will permit of the tongue being pulled quite far back into the fauces ; 
cases are on record where suffocation has nearly resulted from 
such an accident. Again, it must not be forgotten that the ranine 
vessels inosculate just in front of the frsenum on the under surface 



THE TONGUE AND ITS DISEASES. 803 

of the tongue, and might very easily be divided in an operation. 
Many children have lost their lives from such an accident. 

A proper operation consists in making a simple nick midway be- 
tween the tongue and the floor of the mouth : a rupture of the part 
thus effected, the motions of the tongue will quickly secure all the 
latitude required. Should an operation, unfortunately, open a vessel, 
the best, practice would be to secure it with a ligature ; but this 
is not always easy of accomplishment, the artery retracting within 
its loose sheath. An instrument devised by M. Petit to control 
such a hemorrhage consists of a piece of ivory, cut fork-shape, — 
the prongs, of which there are two, passing on either side of the 
fraenum, the short handle resting against the inside of the jaw. To 
apply this instrument, introduce against the bleeding vessel a tuft 
of lint saturated with alum-water or other astringent, then place 
the fork about it, and secure it by pressing it down with the tongue, 
over and around which, and the jaw, a roller is to be thrown. A 
much better means, however, would be the use of the thimble com- 
press, referred to on page 310. Guersent, in his " Surgical Diseases 
of Children," recommends the serre-fine, or the retention, for a time, 
of agaric against the part. Another means, where the wounded 
vessel is not too far retracted to be caught, would be the employ- 
ment of torsion. The use of nitrate of silver or of Monsel's salts 
in these cases cannot be too forcibly discountenanced, the injury 
done by them to the tender parts making secondary hemorrhage 
almost a necessity. 

Swallowing the tongue, as it is called, is a disagreeable accident, 
and may occur without section of the fraenum. Dr. Dewees mentions 
one case in which a child became choked several times a day from 
such a recession. It was always, however, relieved by the nurse, 
who would press the organ down with the handle of a spoon and 
then draw it forward. 

To operate for tongue-tie, it is best to place the body of the infant 
upon the lap of the nurse, the head being received upon or between 
the knees of the surgeon ; the tip of the tongue is then raised, and 
the cut, or nick, made with a pair of curved scissors. 



CHAPTER XXXYIIL 



TUMORS. 



In the following pages the author proposes, after much reflec- 
tion, and after a thorough study of the views and observations of 
the latest writers, German, English, and American, to present to 
his readers the subject of tumors, precisely as in his own clinical 
service he meets with, classifies, and treats such conditions. He 
disregards to a certain extent the classification of others, because 
that which is here adopted seems to him most rationally, philoso- 
phically, and naturally to introduce and evolve the subject. The 
text of the chapter is to be understood as being of a strictly clinical 
signification. In the foot-notes — which, however, a student is 
advised not to read until he has mastered the practical signification 
of the text, thus guarding himself against confusion — will be found 
the views and expressions of pathological histology. 

Such classification of the tumors as is here offered, it is be- 
lieved, opens the subject to the ordinary practitioner with all 
necessary practical clearness, while it must be seen to limit in 
no way the examinations and inquiries of the most inquisitive 
microscopist. 

The surgical expression " tumor" is a term having its origin in 
the Latin verb tumeo, to " swell," and, therefore, necessarily applies 
to any unnatural enlargement of a part, no matter upon what it 
may depend or from what cause it may arise. 

A tumor is a swelling which varies in its nature from that which 
has a signification in some accidental and, it may be, evanescent 
functional derangement — as, for example, a foot cedematous from 
exhausting exercise, an abdomen swollen from accumulated flatus, 
a duct expanded from obstruction of its outlet — to that character of 
an outgrowth which is without explanation in itself or in any phys- 
iological or anatomical association, — a something which, by exclu- 
sion, must be classified as an expression of constitutional meaning 
(804) 



TUMORS. 805 

and signification, — a vice. (In the foot-note will be found the argu- 
ment of Billroth against this premise.*) 

* " When a part of the body is abnormally enlarged, we make a distinction 
as to whether the enlargement is caused by an abnormal increase of the volume 
of the different elements (simple hypertrophy), or by a formation of new ele- 
ments which are deposited between the old ones. The new formation maybe 
analogous to the matrix or mother tissue (homoplastic), or not (heteroplastic). 
The homoplastic new formation proceeds either from simple division of the 
existing elements (thus, a cartilage cell by segmentation forms two, then four, 
cartilage cells: then it is called hyperplastic, numerical hypertrophy), or at 
first apparently indifferent, small, round cells form from the existing cellular 
elements, and from these a tissue analogous to the matrix is developed, — 
homoplastic new formation in strict sense. Heteroplastic new formation 
alwaj^s begins with the development of primary cell tissue, so-called indiffer- 
ent formative cells (granulation stage of tumors — Virchow), and from these 
develops the tissue heterologous to the matrix, as cartilage in the testicle, 
epidermis in the brain, etc. 

" This nomenclature proposed by Yirchow seemed perfectly suitable and 
natural in a purely anatomical point of view ; and I can still accept it, if the 
term heteroplastic be limited, and if we dismiss the idea that homoplastic 
is synonymous with benignant, and heteroplastic with malignant. We must 
here add that there is every probability that wandering cells escaping from 
vessels very materially aid in the formation of tumors, at least in the forma- 
tion of tumors of the connective-tissue series. But, apart from this, we 
should err if we supposed that in the above nomenclature all cases of new 
formations, even considered in a purely anatomical point of view, could be 
easily labeled, ready to be placed away in a museum. The simple numerical 
hypertrophies and hyperplasia, although in some cases difficult to distinguish, 
are at least theoretically separable; the same way with those new formations 
which do not consist of similar, well-formed tissue elements. A connective- 
tissue tumor occurring in connective tissue would always be termed homo- 
plastic; found in bone, brain, or the liver, it would be heteroplastic, etc. 
Well-developed alveolar cancerous tissue also usually presents no difficulty 
of classification, for it does not normally occur in any part of the body ; it is 
everywhere heterologous. But what shall we say of the neoplasias which 
have no fully-developed or entirely abnormal' form of tissue, but consist of 
elements that cannot be found elsewhere ? What becomes of them ? or can 
anything develop from them (indifferent formative cells, primary cell tissue, 
granulation tumors)? and where shall we place those neoplasias which are not 
completed tissue, but are evidently normal tissue in the stage of development? 
According to the above definition of heterology and homology, inflammatory 
new formation is at first heterologous everywhere ; but the connective-tissue 
cicatrix developing from it subsequently becomes a homologous neoplasia in 
connective tissue ; in muscles it almost always remains heterologous ; the 
same way in the brain and in the bones, if it does not ossify. You see that 
here parts which from their nature and mode of origin naturally belong 



806 ORAL DISEASES AND SURGERY. 

The study of tumors is to be pursued from a twofold stand-point, 
clinical and histological. The first has to do with that classification 
of the conditions which directs the practice demanded. The second 
analyzes under the microscope the histogeny of a growth, and 
describes the expressions of its anatomy. 

Clinically, experience would seem fairly to demonstrate that a 
rational primary distinction of the tumors is found in separating 
them into, two classes. One class embraces every tumor that pos- 
sesses a local self-explanation, as, for example, sebaceous tumors, 
ranulae, herniae, hydrocele. The other class comprises all that 
remainder, the explanation of which has to be sought outside of a 
local condition ; examples in this latter direction being recognized in 
the nodes of syphilis, the degenerating glandular enlargements of 
tuberculosis, the multitudinous expressions of cancer. 

All tumors of the first class are, in themselves, of a necessity, 
benign. All tumors of the second class are to be viewed, not in 
themselves, but in the dyscrasia of which they are simply ex- 
pressions. 

Tumors of the first class, having only a local signification, de- 
mand only a local treatment ; tumors of the second class, having, 
save in the accident of the habitat, no local signification, but being 
of constitutional relation, are capable of rational treatment only 
through remedy directed to the vice as it exists in the system at 
large. 

Tumors of the first class may be termed homologous, indicating 

together are sundered by the anatomical nomenclature. But let us leave 
inflammatory neoplasia out of the question. Every tumor resulting from 
indifferent formative cells must exhibit a series of stages of development, if 
the cells are transformed to one or several sorts of tissue. 

" Wherever they are grouped together, indifferent formative cells are 
heterologous ; if a neoplasia shows only such elements, we will let it pass for 
heterologous ; but if it appears that a number of these cells have been trans- 
formed into spindle-cells, the question arises, where does this neoplasia 
belong ? Spindle-cells collected in groups are heteroplastic in all parts of the 
body ; but these cells occur in fcetal connective tissue, foetal muscles, and 
foetal nerves. What would finally become of the spindle-cells of this tumor ? 
If found in muscles, should not this tumor still be called homologous ? On 
this point we can only decide arbitrarily. You may look at it from different 
points of view. Now, what shall we do with tumors which contain the most 
different complete and incomplete tissues ? I will stop here, to avoid making 
you skeptical: it is my duty to help you learn, not to throw obstacles in your 
way. " — Billroth. 



TUMORS. 807 

by this term, not likeness to associated tissue as exhibited by some 
of the neoplasia, but that a tumor is part and parcel of the location 
in which it exists. 

Tumors of the second class maybe distinguished as heterologous, 
indicating simply neoplasia, no matter what the likeness, a some- 
thing which is strictly foreign to any local expression of the part in 
which it is found* 

! . * — 

* " All new formations, not hyperplastic, contain in themselves a qualitative 
departure from the normal processes of development and growth. It there- 
fore appears difficult, at the first view, to place them upon a physiological 
basis. There are, however, not so much actually existing, as much more 
artificially produced difficulties, which stand in our way ; above all, a trans- 
mitted custom of regarding the deviating evil as a frepov, something foreign 
introduced into the organism, of ascribing it to a parasitic existence, even a 
kind of personality. This view, from which the term 'heteroplasia' has 
arisen, has a certain justification: 1st. In the presence of those new forma- 
tions which are caused by a definite poison introduced into the body, and 
conformedly present themselves in the most various organs in the same 
manner, thus in syphilis, tuberculosis, typhus abdominalis. 2d. In the sense 
that every organ has its own peculiar new formations, which always recur 
in the same forms with slight modifications, so that we, if they have pro- 
gressed up to a certain point, may thereupon base a sure diagnosis and pro- 
gress. It is, however, unjustifiable and injurious to the progress of true 
science if one neglects, in the study and description of what the new forma- 
tions of the various organs have in common, the right of the individual 
organ, which requires that one regard the pathological new formations as 
a disturbance of its development, its nutrition, or its decomposition. But be 
it well understood I am very far from disputing the usefulness, nay, the 
necessity, of general observations of pathological new formations. These 
observations, however, ought to proceed more upon establishing the principle 
of development than upon finding out certain anatomical models, according 
to which a new formation, for example cancer, is built, as well in this as 
in that organ. Moreover, if I understand our time, it is tired of purely 
external, anatomical classifications, and decides with me that it has become 
scandalous in the inexhaustible multiplicity of concrete forms. We will, of 
course, therefore speak in what follows of cancers and sarcomas ; we will take 
pains to delineate the laws of their production and their growth in bold out- 
lines, also not to exclude observations upon their effects upon the entire organ- 
ism, therewith, however, constantly reflecting upon the description of the 
individual forms in the special part, and remaining conscious that the knowl- 
edge of these is at least just as important to the physician as is the general 
comprehension." — Rindfleisch. 

" Upon an anatomical basis we must separate those tumors which are the 
result of an actual formative process (pseudoplasms) from those wh ich have 
a different origin. The latter correspond to the majority of what were for- 



808 ORAL DISEASES AND SURGERY. 

Clinical Illustrations, in Diagnosis. — A patient presents 
himself to the surgeon, having a tumor in his groin. What is the 

merly called tumores cystici. Those tumors whicji are not the product of a 
real growth owe their existence either to material that comes direct from the 
blood, or to the accumulation of certain secretions. If the material comes 
from the blood, it may be deposited in three forms : 1, Blood in substance, — 
extravasation : 2, serum, containing water, salts, and albumen, — transudation ; 
or, finally, 3, a certain amount of fibrin with the serum, — exudation. In 
some instances there will be found an exudation and an extravasation together 
in the form of a hemorrhagic exudation ; or with a large amount of serum 
there will be found a small quantity of fibrin, — a serous exudation. 

" Those tumors which represent the accumulation of certain secretions 
differ in the following respects : the contents may be chiefly fluid, or chiefly 
organized elements, or may consist of both. These cystic tumors form a class 
by themselves. The accumulation takes place in a pre-existing space, which 
becomes dilated or ectasic in proportion to the accumulation of the secretion. 
These tumors could be called ectases, but there is something besides ectasis, 
namel} 7 , the retained secretion. "We shall, therefore, call them dilatation or 
retention tumors. 

" The tumors of the first class, which consist chiefly of the elements of the 
blood (extravasations, transudations, or exudations), may either originate in 
a pre-existing space, or form for themselves a new space. These we shall call 
extravasation or exudation tumors. 

"In this way, leaving out the entozoa and simple swellings, we obtain 
three large groups or classes : first, the exudation and extravasation tumors ; 
second, the dilatation and retention tumors; and last, the true pseudoplasms 
or neoplasms, — the growths in the strict sense of the word. The last class, 
as we have already seen, may be again divided into three smaller classes : the 
simple histoid, the organoid, and the teratoid tumors. Unfortunately, the 
classification cannot stop here, for there are many tumors in which different 
varieties are combined together. These are called combination tumors. In 
some cases these combination tumors are exceedingly difficult to comprehend. 

"All heterologous tumors are not malignant. Quite a number of them are 
practically benign, and may be carried without ever causing any special 
trouble. In the first place, there are degrees of heterology. The tissues 
belonging to the group of connective substances are more nearly related to 
each other than to the epithelial tissues. If, therefore, a cartilaginous or 
bony tumor originates in the midst of connective tissue, or a myxoma (mucous 
tissue) in adipose tissue, the heterology in these cases will be far less than if 
an epidermoidal tumor were to originate in the midst of a lymphatic gland. 
A matter of still greater importance is the extent to which a tumor can pro- 
duce fluid material, that may be pressed out like a juice. This parenchyma- 
tous juice is at one time deposited within the cells (intracellular), at another 
between them (intercellular). A tumor containing much juice possesses to a 
high degree the power of infection. A dry epidermoidal tumor is much less 
dangerous than a moist one ; a soft cancer is much more suspicious than a 



TUMORS. 809 

nature of this tumor ? It might have the local signification of a 
hernia ; of an undescended testicle ; of a hydrocele of the spermatic 
cord ; of an inflamed lymphatic gland. It might have the consti- 
tutional explanation of syphilitic or of tuberculous bubo. It might 
be a cancer. To satisfy himself of the particular condition repre- 
sented, the surgeon can only proceed as follows. First, he must 
recall the anatomy of the part. In the groin of the human male is 
a canal, — the inguinal canal. This canal is entered by a ring from 
the abdominal cavity, and has an outlet in a second existing in the 
aponeurosis of the external oblique muscle. In this canal lie, en- 
veloped in a sheath, the spermatic vessels. This canal constitutes 
the passage transmitting the testicle from the abdomen to the scro- 
tum. The entrance to this canal may permit of the insinuation of a 
knuckle of omentum or intestine. In this inguinal region exist a 
number of lymphatic glands. This, then, is the anatomy, and these 
are the data. Is the tumor a hernia ? There is no impulse on cough ; 
no doughy feel ; no diminution in size when the patient lies down ; 
no ability to thrust the tumor into the abdomen ; no enlargement of 
the internal inguinal ring. The tumor is not a hernia. Is it an un- 
descended testicle ? The testicle is to be felt in its place in the scro- 
tum. The tumor is not a testicle. Is it hydrocele of the spermatic 
cord? There is no fluctuation on percussion; no ability to change 
the position ; no fluid as test is made with the exploring-needle or 
suction syringe. It is not hydrocele. Is it an inflamed gland of a local 
inflammatory signification ? It has no such history. The tumor, 
then, is not of immediate signification ; this, it would seem, we must 
know to a certainty. By exclusion, then, such tumor is exhibited as 
belonging to the second class. The only question now is as to the 
vice represented. Syphilis and tuberculosis have a history. If such 
history does not exist, then a final exclusion pronounces the condi- 
tion — whether rightly or wrongly need not here be discussed — a 
cancer. 

Example. — At a late clinic of the University Hospital there ap- 
peared before the class five patients. These patients, suffering alike 
from swollen, enlarged cheeks, were ranged side by side for diag- 
nosis. Patient 1 was found to have the tumefaction dependent on 

hard one. The fewer vessels a tumor possesses, the more will its infecting power 
be restricted to the immediate neighborhood ; but the richer it is in blood- and 
lymph-vessels, the closer the contact of these tioo fluids with the parenchymatous 
juices, and the easier will the infection become general.' 11 — Virchow : Abstract 
from Lectures, made by Drs. Buck and Delafield. 



810 ORAL DISEASES AND SURGERY. 

a periodontitis; patient 2 was laboring under caries of the jaw; 
patient 3 suffered from necrosis ; patient 4 had a lymph effusion con- 
sequent on a fracture ; patient 5, with very limited swelling of the 
cheek, associated with enlargement of the maxilla, presented in his 
case no local or common systemic explanation ; it became thus 
a necessity to pronounce the disease associated with the vice of 
cancer. The first four patients, their cases being self-explaining, 
were quickly made well ; the last — whose case was without an 
accounting explanation — died, and died from that condition which, 
in its developed state, was by all called carcinoma. 

With the premises of the preceding pages, for the purposes of 
the chapter, assumed, it is to be understood that any tumor, wher- 
ever situated, being without a history which explains it, is to be 
called and treated as cancer. But here at Once may seem to rise 
insurmountable objections to such classification. It might be urged, 
for example, that a spindle-cell sarcoma which shall not destroy life 
has no more explanation of its origin than has an encephaloma, 
which in a single year runs to a fatal end. Such objection, however, 
influences only the histologist ; the clinician recognizes no prac- 
tical difference between the two conditions : they are, he assumes, 
but expressions of a common vice.* But the one will kill, and 
the other may not. If this is urged, the objection is admitted ; but 



* " Over no group of tumors has there so long been uncertainty about their 
anatomical position and extent as about sarcoma. The old name, taken from 
oaptj, flesh, merely meant that on section the tumor had a fleshy look. Of 
course, this did not make a diagnosis, as it was greatly a matter of choice 
what should be called flesh. The attempt to employ the name sarcoma solely 
for tumors composed of muscle filaments (Schule), that is, to identify it with 
those tumors now called 'myoma,' was not popular. Subsequently the term 
became somewhat more definite, — it was made to include all tumors rich in 
cells which have no decided alveolar formation, and were not carcinomatous. 
It is only for the last ten years that the following histological definition has 
received general acceptance, and has become quite common. A sarcoma is a 
tumor consisting of tissue belonging to the developmental series of connective- 
tissue substances (connective tissue, cartilage, bone, muscles, and nerves), 
which, as a rule, does not go on to the formation of a perfect tissue, but to 
peculiar degenerations of the developmental forms. Some pathologists would 
gladly see muscles and nerves excluded from this definition ; but when speak- 
ing of the spindle-celled sarcoma I shall show why I cannot admit this. If it 
is desired to term the inflammatory neoplasias in their various stages examples 
of sarcoma (Kindfleisch), I assent to it, as this definition would agree pretty 
well with mine." — Billroth. 



TUMORS. 811 

it has an explanation which is easily made evident. There is, we 
say, but one non-explaining vice ; this vice puts on various phases. 
These phases are influenced by the malignancy of the poison, or by 
relation with the conditions of the individual into whose system it 
has found ingress. This we may illustrate by an example. Four 
men go from a healthy to a malarious district ; all live in the same 
house, and all impregnate their systems with the same poison. In 
a week one succumbs to a quotidian ; in two weeks the second has 
a tertian; in three weeks the third dies from congestive chill; while 
the fourth, preserved by an inherent resistive force, antagonizes the 
miasma entirely. Thus also in the cancer vice : one man, either 
from the concentration of the virus or from the absence of antago- 
nizing power, dies quickly from a medullary expression; while an- 
other maintains a tumor for years, in the expression of simple sar- 
coma, succumbing finally in the battle, which, by the accident of some 
loss of force, gives a mastery to the abeyant vice, the sarcoma being 
quickly degraded into that which the microscope has distinguished 
from it as carcinoma. (See Sarcomatous Carcinoma.) 

The premise, then, is to be maintained, that any and every tumor 
which cannot be proved benign is to be deemed malignant. A 
self-explaining tumor expresses its own name ; a non-explaining 
tumor demands from us no special regard for the distinctions of 
nomenclature, except as in an adjectival way the distinctions classify, 
for convenience in description, what are to be regarded as varying 
expressions of a common disease. (See Fibroma.) 

Urging the conviction that in the preceding few and very simple 
rules lies the fullness of a proper clinical diagnosis of tumors, appli- 
cable to any and all cases, we may now, without the chance of 
becoming confused, proceed to acquaint ourselves with the tumors 
pertaining to the parts which it is the special object of this volume 
to study. Before doing this, however, a comprehensive discussion 
of the subject at large may, with greater justice to our distinctions, 
invite the attention of the student.* 

* But it is to be asked whether or not, outside of the negation of the self- 
explaining tumors, there is a something that may distinguish a cancerous 
tumor ? If there is, the author knows nothing about it ; but this negation 
has a wide meaning. According as a man knows of a certainty what is not 
cancer, his inference of cancer becomes reliable and valuable : he calls that a 
cancer which has its place outside of the positive diagnostic. 

But is there not some special histological expression which characterizes 



812 ORAL DISEASES AND SURGERY. 

1. Relationship. — Homologous tumors tend, as would be in- 
ferred, to preserve their individuality; a malignant growth, on the 
contrary, represents simply the nidus of a vice flowing in from all 
parts,* and unless this poison become exhausted, or be powerfully 
resisted, it is seen to tend to infiltration and a commingling with all 
adjacent tissues. 

2. Homologous tumors progress regularly, are apt to remain 
stationary after attaining some certain size, as in an odontocele, or 
they may degenerate and slough, as seen frequently in nsevi and in 
the sebaceous growths. In structure, homologous tumors are akin 
with the parts in which they are found ; they do not possess other 
than a single formative capacity. The tumors of a vice, on the 
contrary, have, as a rule, associated with them the evidences of 
their systemic character. They are not amenable to a local cure : 
if one be removed, a second comes to take its place, appearing either 
in the site of removal or in some other locality.f The cure of a 
vice tumor resides either in the use of a specific, antidoting the 
poison of the vice, or in affording such increase of the natural 
resisting force that the destructive tendency is retarded or over- 
come. 

3. Homologous tumors are commonly single, or, if multiple, — for 
example, sebaceous cysts, — are confined to a common tissue and a 
common association. The vice tumors exhibit their constitutional 
association in the tendency, as just remarked, to reproduction not 
only in various parts, but in various tissues. 

4. Homologous tumors, if painful, express a common pain. Yice 
tumors are apt to have a character of pain peculiar to themselves. 

1. Simple Inflammatory Tumors. — A simple inflammatory tumor 
refers to a swelling (which is of varying nature), associated with an 
inflammation : thus, it may depend on simple excess of blood in a 
part, or on effusion of serum or of lymph. 

Vascular excitement, of a grade which brings a perverted circula- 
tion under cognizance as inflammation, never increases the dimen- 

cancer, — some peculiar heteroclitic cell ? Once it was thought so ; but now it is 
known that the spindle-cells, deemed a few years back entirely diagnostic, are 
also found in foetal connective tissue, muscles, and nerves. Spindle-cells 
afford information to diagnosis from location and combinations alone. 

* This view has the indorsement of the eminent surgeon and pathologist, 
Mr. Paget. 

f This is attempted to be explained by Virchowon the principle influencing 
syphilitic absorption, or rather, to express him more critically, by embolism. 



TUMOBS. 813 

sions of a part through excess of nutritive or formative action ; on 
the contrary, the nutrition of an inflamed part is always diminished, 
this being amply demonstrated by the disorganization of suppura- 
tion. Even, however, in the cases where resolution occurs, the 
tissues are always left relaxed and degenerate, and in themselves 
are, without doubt, of less consistence by weight or bulk than before 
the attack. 

It is, however, as is well understood, a characteristic of vessels 
engaged in inflammatory action to relieve their distention through 
effusion, and thus, as such effused material may be serum, fibro-serum, 
blood, or lymph, tumefaction is produced, which is persistent or 
otherwise according to character and associations. 

Concerning the first, — the simple, unmixed watery effusions, — they 
are found most frequently associated with low degrees of inflamma- 
tion, as in certain articular affections, in eneephalocele, hydrocele, 
etc. In such effusions there can be no tendency either to coagulation 
or to organization : a tumor is formed, but it is simply a water-bag. 
Fibro-serum, or serum containing fibrin, has in it, however, an 
organizing force proportioned to the quantity of fibrin contained, 
approaching to this extent the nature and character of lymph : such 
fibro-serum is seen, on withdrawal from the body, to differ from 
serum proper in the ability it possesses to assume a jelly-like con- 
sistence, and, indeed, to show the fibre-cell, as exhibited in the peri- 
toneal and pleural effusions. Fortunately, however, while excluded 
from the air, fibro-serum seldom manifests any tendency to coagulate, 
thus remaining as susceptible to the action of the absorbents as is the 
more simple effusion. Fibro-serum is the liquor sanguinis of Babing- 
ton, the plasma of Schultz, the mucago or mucilage of Harvey. 

Lymph, another of the exudates of an engorged vessel, finds its 
most practical expression when viewed as the agent of nutrition ; it 
is that pabulum in which reside the elements of life, and is in 
a state of constant transmission to every part of the organism: 
only as the result of over-pressure or engorgement, however, is it 
likely to be found in excess in any one part ; but when so found it 
compels a tumefaction, to the proportion, of course, of the amount 
exuded. 

Between lymph and the vitalizing principle — the vis vitse — there 
exists the most marked affinity ; so that the circumstances must be 
adverse indeed where exuded lymph does not tend to organization. 
Corpuscular lymph, as it is sometimes termed, to distinguish a less 
vital from fibrinous lymph, is, when employed — as is not uncommon 



814 ORAL DISEASES AND SURGERY. 

— to express the existence of two kinds of lyniph, a physiological 
misnomer, — the difference lying not in kind, but in character: thus, 
while lymph exuded by a vigorous organization tends always to 
immediate organization, cells being developed in the blastema, and 
fibres developing from cells, in a specifically diseased person, or in 
one deficient in the vital element, the recognition of cause for de- 
generation is sufficient explanation of a corpuscular variety. Cor- 
puscular lymph is protoplasm the grade of organization of which 
fails to rise to a proper development ; the very common admixture 
of these two varieties is evidence enough of the oneness. 

Lymph tumors have associated with them a threefold sequel se : — 
the contents are absorbed ; or they organize ; or they degenerate 
and are gotten clear of in suppuration: or the three conditions may 
coexist, part of the lymph being absorbed, part being thrown off by 
degeneration and suppuration, and a portion affiliating itself with 
the surrounding parts. 

2. Hypertrophic Tumors. — Hypertrophy is an expression of 
unbalanced nutrition, — a part, from some reason (recognizable, or 
not so), developing in excess of its fellow-parts. Hypertrophic 
tumors differ from all others, however, in their perfect and complete 
conformity with the parts with which they may be associated. So 
marked and characteristic is this that it is only through comparison 
with neighboring parts that the tumefaction or enlargement is to be 
perceived. Hypertrophy may ensue from the opposite conditions 
of excessive supply or of diminished waste. The enlarged biceps 
muscle of the blacksmith, and the gastrocnemii of the ballet-dancer, 
are illustrations of hypertrophy from super-nutrition. Enlarged 
glands from tuberculosis are not justly to be considered in such a 
connection, being specific hypertrophies : the first are hardly to be 
pronounced pathological, the latter are necessarily so ; the first have 
no expression but health, the latter none but disease. 

3. Tumors which result from Interference with Function. — The 
appreciation of this class of tumors, of which there are a great 
number, is commonly without confusion or difficulty. It is, of 
course, required that the observer shall draw his inferences from the 
data of an anatomical and physiological knowledge. The opened 
spinal canal gives the protruding meninges, — the fluid of the cord 
filling the fluctuating cyst ; obstructed sebaceous ducts yield wens ; 
relaxed veins afford varices; occlusion of the antral foramen compels 
engorgement of this cavity ; an unclosed umbilicus, or attenuation 
of its structures, and hernia follows ; a tooth out of the dental 



TUMORS. 



815 



arch, yet developing within the structure of the bone, and odon- 
tocele is apt to ensue. So of all this class of tumors we have similar 
simple and single significations ; the pathology of each is peculiar 
to itself, but may be esteemed as almost strictly mechanical. 

4. Blood Effusion. — It not unfrequently happens that an inflam- 
matory engorgement is associated with rupture of certain of the 
minute blood-vessels, thus allowing of the mechanical pouring out 
of the blood into neighboring parts. Such tumors find diagnosis in 
the suddenness of their formation and the associated inflammatory 
condition ; they are simply blood-bags, which may be more or less 
sacculated according to the circumstances of location. A blood effu- 
sion differs so markedly from a nasvus or erectile growth, that by 
no possibility could these be confounded. Blood effusions may be 
absorbed, may be organized, or may degenerate and break down, 
being gotten clear of through the suppurative process. 

Another class of blood tumors are of traumatic signification. A 
hematocele is not unfrequently resultant from injury rupturing 
vessels. The common blood blister is an example familiar to every 
one. 

Histological Distinctions. — A common classification of tumors, 
as employed by nearly all writers, is founded on what are termed the 
histological aspects of the growths described. The philosophy of 
such classification finds condemnation in the changes constantly 
occurring, and in the fact that the clinical history of the conditions 
demonstrates the expressions to be phenomenal, just as, though in 
more marked degree, the expressions of vascular perversion which 
we denominate inflammation are phenomenal. 

The classes of tumors, as histologically described, are as follows : 



Cystoma Cystic. 

Enchondroma ...Cartilaginous. 

Fibroma Fibrous. 

Lipoma Fatty. 

Osteoma Osseous. 

Dentinoma Dentinal. 

Hematoma Blood. 

Encephaloma .. . . Brain-lik e. 

Scirrhoma Marble-like. 

Melanoma Like black pigment. 

Myxoma Mucus-like. 



Adenoma Glandular. 

Angionom a Vascular. 

Sarcoma Fleshy. 

Neuroma Nerve-like. 

Hygroma Water-like. 

Steatoma Lard-like. 

Myeloma Marrow-like. 

Meliceroma Honey-like. 

Atheroma Gruel-like. 

Chloroma Like green pigment 



816 ORAL DISEASES AND SURGERY. 

A single moment's reflection will show that no conflict can exist 
between such a histological classification and the clinical one here 
proposed. An angionoma may be homologous or heterologous. A 
hsematoma may be benign or malignant. Let us analyze, in illus- 
tration, some of the terms. 

We say, for example, of a certain tumor, that it is a cystoma. 
Using this term, we imply in it a cystiform character of growth, — 
this, and nothing more. The tumor may readily enough be what 
we have called homologous ; for should the cyst be in the jaw-bones, 
and should we make examination, we might remark the absence of 
certain teeth from the arch affected, and, on chiseling off the vault 
of the cyst, we might find the lost teeth as an explanation of the 
growth: the cyst would be a self-explaining odontocele. 

Again, examining a similar form of cyst, we find no teeth absent 
from the arch ; no diseased teeth, nothing that has in it the sem- 
blance of explanation ; the most accurate inspection, founded on 
the most profound knowledge of the parts, reveals no cause why 
a cyst should have developed in such place and at such time. Here 
the most experienced surgeon has but a single resource. He must 
act on the premise that the condition is the expression of constitu- 
tional vice, — not that this would necessarily be so, but that he does 
not know it be otherwise ; and therefore, not seeing or knowing what 
is to be done, his best plan will be to do nothing, — awaiting develop- 
ment, — or else treat the cyst with the latitude of cancer. 

Take a third condition of cyst, — a cyst in the substance of the 
lip. Is this homologous, or is it heterologous ? Is it a self-explaining 
condition, or does it express the habitat of a vice ? 

In the substance of the lip are secreting glands of three characters, 
mucous, sebaceous, and sudoriparous; each of these, for the purpose 
of clinical study, may be described as a secreting cyst-like body with 
a patulous tube running from it to a free surface, through which 
tube is constantly being discharged the fluid formed in the cyst. 
Suppose now any one of these tubes to be accidentally occluded, 
we find ourselves led at once to au apprehension of a diagnosis. 
Should a labial cyst be mucous in its character, it will be a soft, 
more or less elastic tumor, will be situated upon the oral aspect 
of the lip, and if explored by the needle will yield the characteristic 
discharge. Should the cyst, on the contrary, be of a sebaceous 
nature, it will be related with the external tissue, will roll loosely 
under the touch, and if explored will exhibit cheese-like contents. 
The sudoriparous cyst is, of course, of very rare occurrence ; if 



TUMOBS. 817 

existing, it would also lie in the external tissue, and would be found 
to have much more elastic walls than either of the others. A cyst 
sometimes will be found in the lip dependent upon dental abscess. 
A case is at the present time under treatment by the author where 
such a cyst has been of eleven years' standing; during all this 
period the tumor has not been of less size than an ordinary shell- 
bark-nut. The sac was found very thick, and the surface ulcerated. 
A treatment which consisted simply in the extraction of two dead 
teeth, has resulted in the entire disappearance of the cyst. The 
alveoli of these teeth were found to associate with the tumor.* 

We pass to other of these synonyms. Let us take the terms 
scirrhoma, myxoma, encephaloma, myeloma: these are names given 
to tumors because of peculiarities of structure. The clinical placing 
of them, however, is the practical matter. Whatever name the his- 
tologist employs for the designation of a tumor, whatever may be 
the histology of the growth, its clinical place, if no local explana- 
tion exists, is with cancer. Here only may it be placed as treatment 
is concerned, and with such latitude of doubt, however profound may 
be his histological learning, is the surgeon made to feel that he 
must treat it. 

Scirrhoma is a term employed to designate solidity, hardness ; the 
cancer vice, influenced by the associations of a part in which it is 
found, by its own character, or by some peculiarity or idiosyncrasy of 
the individual, exhibits itself as a hard nodule ; remove this nodule, 
and not unlikely the return of the disease is in the form of a brain- 
like substance, — encephaloma ; or that might come, which, cut into, 
would exude a mucus-like substance, and we might call it a myx- 
oma ; or perhaps a section would exhibit marrow-like contents, — 
myeloma; or there might be a cyst with gruel-like contents, — 
atheroma. Or, diffused throughout the substance of any of these 
differently appearing conditions, there might be a black coloring- 
matter, — then we might express the tumor as a melanoma ; should the 
pigment be of a green shade, we would call it chloroma ; or should 
we designate the tumor for the first time, on seeing it in a state of 

* The hydatid, being a cyst of parasitic origin, is not introduced. Such a 
cyst, being an accident, as it were, can be conformed to no rule. For pur- 
poses of treatment, however, these tumors, however much they might be 
misjudged, have every requirement met in such operations as consider the 
circumscribed and antagonized cancer growth (which see). The clinical 
distinction makes necessarily unimportant the mistake— as treatment is 
concerned— of classifying the hydatids with the cancer vice. 

51 



818 ORAL DISEASES AND SURGERY. 

fungous proliferation, we should call it a hsematoma. Yet, with all 
these various significations, we would mean, in truth, but a single 
thing: and to clinically classify any or all of these phases we would 
need but one common term, — that is, taking it for granted that the 
tumors were without local explanation. In such exposition of 
terms, which are seen to be simply expressive of types, — synonyms 
we may with all propriety call them, — any confusion must certainly 
be found dispelled. These various terms, as employed in writing, 
are, however, of great assistance in expression; it is only necessary 
to bear in mind that their meaning and relation are adjectival. 



CHAPTER XXXIX. 

THE TUMORS OF THE MOUTH. 

THE EPULIDES. 

The Epulides. — The tumors of the mouth most frequently met 
with are those seen growing upon the gums, and known as the epulic. 
These growths are, in almost all instances, first to be observed 
making their way from about the neck of some particular tooth, 
pushing out, apparently, from the socket, being found to originate 
from the odonto-alveolar membrane. 

As the epulides, like other tumors, classify themselves into self- 
explaining and non-explaining, the term epulis, still in quite com- 
mon use, is without proper signification when employed as a noun 
substantive, being possessed of an adjectival sense only. This term 
is derived from the Greek words bc( and oZka, signifying " upon the 
gums," and will be seen, therefore, to express simply position, so 
that, in employing it, one can only express that the growth spoken 
of is upon these parts. 

Histologically expressed, the epulic tumors might be classified as 
follows: epulo-fungoid, epulo-erectile, epulo-fibroid, epulo-fibro-recur- 
ring, epulo-sarcomatous, epulo-myeloid, epulo-carcinomatous, epulo- 
cartilaginous, etc. Clinically classified, we have to concern our- 
selves only with the benignancy or malfgnancy of the growths, as 
thus alone may we be led to a required treatment. 

The single epulic tumor which may with certainty be known as 
benign is the pulp-fungoid. A second form, which is usually found 
so, is the erectile. Any of the epulides which does not exhibit itself 
as one or the other of these forms is to be deemed cancerous, and 
treated with the latitude given to cancer. No other inference in- 
sures the best good for the patient. 

An epulo-fungoid growth is self-explaining. An erectile tumor 
is fairly so from analogy with the naevi : it is, in fact, a naevus. 
No other of the epulides possess explanation of their presence or 
development. The epulo-fungoid growths demand a treatment pecu- 

(819) 



820 



ORAL DISEASES AND SURGERY. 



liar to themselves ; so, also, do the erectile. All the other epulides 
are to be treated on a common principle. From such data, which 
may be accepted as solidly reliable, the surgeon is led to perceive 
that an appreciation of the first two insures the clinical understand- 



ing of all the other conditions. 





The Epulo-Fungoid Tumor. — By an epulo-fungoid tumor is meant 
a fungoid growth of an exposed degenerating dental pulp. This 
tumor is as common as it is simple and harmless, and is certainly to 
be seen in a thousand cases to one of any other form. The fungoid 
pulp tumor is met with under the various aspects exhibited in Fig. 
249. 

Referring back to Fig. 44 and description, the dental pulp is 
recognized as a stroma of delicate connective tissue, in which stroma 
ramify blood-vessels and nerve-fibrillae ; this structure occupies the 
cavity of the tooth, and is liable, through the accidents of decay or 

fracture, to become exposed. 
_ Fig. 249. When exposed, it is not 

unlikely to undergo fungoid 
degeneration. Fig. 249, 
Subfig. 1, is an outline 
drawing representing the 
walls of a tooth-root envel- 
oping its pulp, which pulp, 
slightly fungous, projects a 
trifle above the level of its 
cavity. In molar roots, the 
crown being gone, such form 
of pulp tumor is very com- 
mon. No difficulty exists, 
however, in its recognition, 
as the boundary-walls of the cavity are plainly to be observed. A 
form of such tumor, a trifle complicated, is exhibited in Subfig. 2 : 
here, as is seen, the fungus is of such extent as to overlie the bound- 
aries of its canal; any confusion is avoided, however, by thrusting 
the mass aside, when its character is at once made evident. Sub- 
fig. 3 represents another condition : here the mass has increased to 
such an extent that it not only conceals the canal, but also rests upon 
the surrounding gum, to which, not unlikely, it will be found to have 
formed attachments. Still another form is exhibited in Subfig. 4. 
Here a tooth-root may be below the border of its socket. No 





Epulo- or dental fungoid tumor. 



TUMORS OF THE MOUTH. 



821 



Pig. 250. 



pulp projects from the face of the canal, but a break exists 
upon one side of the root, out of which grows the fungous mass. 
Such a growth, little by little, insures the absorption of the alveolus 
upon the side at which it projects, and rising, finally, above the 
free face of the gum, exhibits a condition well calculated to mis- 
lead. Such a tumor is readily distinguishable from the odonto- 
periosteal growths by the nature of the growth, being of a livid 
asthenic appearance, not common to any other of the epulides. 
This last form of tumor is not at all frequent, depending for its ex- 
istence upon such a break in the continuity of a tooth-root as seldom 
occurs. It is to be remembered, however, that a decay commencing 
at the free surface may run along the root of a tooth, out of which 
track may project the fungus. 

Fungus of the dental pulp, of an extent and character described 
in conditions 3 and 4, is, however, as unfre- 
quently to be met with as conditions 1 and 2 are 
common. 

A form of epulides simulating, as location is 
concerned, the pulp-fungus, is exhibited in Fig. 
250. In this instance the tumor, while seen to 
arise from the pulp cavity of the fang, when traced, 
is found to be an outgrowth of that aspect of the odonto-periosteai growth 

,..,.." simulating pulp-fungoid. 

odonto-periosteal membrane which adjoins the 
bone ; the growth has passed through an opening in the root, and 
has progressed, as shown in the dotted lines, until, reaching the 
margin, the tumor becomes exposed. The drawing shows the tooth 
in section. 

To mistake this last form of growth for the ordinary pulp- 
fungus would be to err necessarily in the treatment, the four condi- 
tions represented in Fig. 249 requiring either the destruction of the 
fungus by means of cauterization, or the extrac- 
tion of the affected fang; while this necessitates 
section of the portion of the jaw found implicated. 

Still another form of epulic tumor* con- 
sists, as exhibited in Fig. 251, of a ulitic out- 
growth, the result of irritating influences asso- 
ciated with double proximal dental caries ; the 
gum tissue, semi-strangulated, rises and fills the 
cavities. A similar expression of tumefaction 




Fig. 251.— Ulitic 
Tumor. 




* This, from its simplicity, is to be classed with the pulp-fungoid, as it 



equall} r self-explaining 



822 ORAL DISEASES AND SURGERY. 

is not unfrequently met with in the interspace existing between 
teeth in which the V-cut has been made ; indeed, these growths are 
to be met with where they have not only completely filled this in- 
terspace, but so projected above the grinding face of the teeth as 
to be injured at every occlusion of the jaws. The treatment consists 
either in extracting one of the approximating teeth, in so altering 
the relation of the necks of the teeth as to obviate the strangulation, 
or, after cutting away the mass, and by means of cotton wedges 
forcing the structure entirely clear of the cavity, in restoring by con- 
tour filling the original relation of the parts. A temporary treatment 
consists in keeping the cavities filled with plugs of cotton saturated 
with gum sandarac. 

Reviewing the tumors just described, it is seen that, with a single 
exception, — that shown in Fig. 250, — all are self-explaining. 

Epulo-Erectile Tumor. — This is a vascular growth, the analogue 
of the naevi ; it is commonly associated with the capillary system, 
and has its character marked by its variation in size and appearance 
as influenced by the conditions of the circulatory system at large, — 
excitement increasing its turgescence, quiet reducing it. Erectile in 
a general appearance, epulo-erectile tumors present, however, decided 
features of variation. Thus, some represent a congeries of vessels 
which would seem to need the merest scratch to result in profuse 
hemorrhage. A more common feature of vascularity, however, 
exists in a likeness with the tissue of the corpus cavernosum penis, 
the cellular stroma being thinned into a series of communicating 
cells, which are found congested or otherwise, as circumstances 
control. Erectile tumors are also not unfrequently found quite solid, 
simulating fibrous structure : this depending on some vascular per- 
version which has produced excess of the fibro-cellular element ; 
indeed, it has sometimes happened that spontaneous cure has been 
effected through lymph effusions. The surgeon, acting on the hint 
furnished by nature, employs such process as one of his means 
of cure. Of the various forms of the epulo-erectile tumor, the 
spongoid is, however, by far the most common, — is, indeed, to be 
considered the type : stimulation of the circulation will fill it at 
times to bursting ; pressure may almost completely empty it. 

Whether an erectile tumor may come under the definition of 
arterial, venous, or capillary, depends simply on the vessels most 
involved. The term aneurism by anastomosis, applied to these 
tumors by John Bell, seems to have had its foundation in that 
variety in which the arterioles are most implicated. This species, 



TUMORS OF THE MOUTH. 823 

when congested, presents the arterial hue, and, when accidentally 
wounded, is the most troublesome, as control of hemorrhage is 
concerned. The venous variety is made up of a congeries of 
venules: the tumor is dark and commonly somewhat sluggish in 
aspect. The capillary form is intermediate between the arterial 
and the venous, and constitutes the spongoid form. The under- 
lying bone of the erectile epulides will almost invariably be found 
involved, being softened and spongy. Erectile tumors sometimes, 
though rarely, make their first appearance as a red pimple upon the 
gum, growing in a polypoid form until they may attain the size of 
a cherry. 

Treatment. — Erectile tumors involving the bone can be cured only 
by a section which includes this structure. The diagnosis is easily 
secured by passing an exploring-needle through the soft tissue : 
if the bone is implicated, the needle will be found to enter it freely, 
and may be moved about among the loose stroma; if the needle 
does not pierce the bone, and the tumor is at all pedunculated, it 
may be strangulated; or, even where the base is broad, the ligature 
may yet be used, transGxing first the base with one or more 
needles for the proper directing of the thread. 

A second mode of treatment is by injection ; the ordinary hypo- 
dermic syringe being employed, charged with one of Monsel's 
solutions of iron, with a very concentrated tincture of iodine, or with 
the glacial acetic acid. Any substance which will coagulate the 
blood may be employed, and not unfrequently is found to answer a 
very satisfactory end. The employment of this means of cure is 
not, however, unattended with risk. Still another method consists 
in the application of caustics, such as chloride of zinc, Vienna paste, 
the London paste, or the strong mineral acids. An anxiety, how- 
ever, which must always accompany the employment of these 
agents, is the fear of hemorrhage on the casting of the slough ; 
and such anxiety is so well grounded that experience soon teaches 
that this means of cure is applicable only in the least vascular of 
the gr'owths. 

The seton, as an agent, finds not unfrequently its most happy ser- 
vice in the erectile epulides. The needle used is that employed 
by the surgeon in the passing of the ordinary ligature silk. The 
seton may be soaked or not in some caustic solution ; the thread is 
always to be the thickest that the eye of the needle will admit, in 
this way insuring the occlusion of the transfixed vessels and 
guarding against bleeding. When hemorrhage associates itself 



824 ORAL DISEASES AND SURGERY. 

with such transfixion, alum-water may be held in the mouth ; or, if 
this does not answer, tannic acid may be drawn into the wound 
by coating the seton and moving it gently backward and forward. 
Should even this not control the bleeding, a knitting-needle heated 
to whiteness may be thrust through the wound, or the saturated 
tincture of iodine may be injected. On two or three occasions the 
author has found himself enabled to control such a hemorrhage by 
casting a ligature around the parts, as best might be done, thus 
cutting off the circulation ; indeed, the practitioner, using the 
seton, will on some occasions find the employment of the ligature 
forced on him. Such hemorrhages are, however, very infrequent, 
and may not be met with in one out of a hundred cases. They 
are most commonly associated with the arterial variety of tumor. 

Electrolysis is another means of treatment sometimes employed 
(see Treatment of Nsevi), and is highly lauded in its application; 
the object should be the coagulation of the blood, rather than a 
cauterization of the stroma of the tumor. Although destruction is 
preferred by many as the best service of electrolysis, it is to be 
recognized that the mode of using the agent suggested has the ad- 
vantage, inasmuch as it is a certain insurance against hemorrhage. 

A practice of " piecemeal removal" has been introduced into 
English surgery, consisting in teasing or tearing or twisting 
away fragment after fragment ; the principle being to avoid hemor- 
rhage, as in the torsion of arteries. This is a practice, however, 
which the inexperienced will do well to avoid ; not but that, in 
certain cases, it is a good plan of treatment, but frequently it 
has troublesome associations, not the least of which is active 
hemorrhage. 

Still another treatment, employed where a tumor has no asso- 
ciation with the bone, is the employment of the serres-fines : these 
are spring-wire forceps ; they are to be made of a size propor- 
tioned to the requirements, and may be clamped over the mass. In 
using these clamps, regard must be had to the nature of the serra- 
tions, these being deep or shallow according to the vascularit} 7 " of 
the part to be grasped ; the pressure of these clamps will not un- 
frequently result in a coagulative and inflammatory action, which 
proves the cure of the tumor. 

An application somewhat on the principle of the serres-fines is 
the employment of pressure. The parts having first been emptied 
by forcing out the blood, a well-adjusted compress is to be bound 
tightly over the tumor, and retained in place continuously for 



TUMORS OF THE MOUTH. 825 

several days : this treatment, when the growth is small, will often 
effect a cure. An admirable plan of securing a desired pressure in 
these cases is to take an impression in wax of the jaw on which the 
tumor is situated, and, obtaining thus a model, make a plate precisely 
as for artificial teeth, having bands to hold it firmly in place, fitted 
to clasp neighboring teeth ; by now placing over the tumor a layer 
of cotton-wool, and compressing it by fitting the plate in place, 
pressure of a very effective type will be found to have been secured. 
Advantage is also gained by employing astringents in conjunction 
with the plate ; saturating the wool with a diluted solution of Mon- 
sel's solution of the persulphate of iron answers a very good pur- 
pose, or tannic acid or alum may be used. 

The erectile forms of the epulides, while not so clearly explainable 
as the pulp-fungoid, are yet to be esteemed as of local signification 
and of innocent type. An analysis of an erectile growth exhibits it 
as a tuft of vascular tissue. We recognize in it vascular anatomical 
perversion, not the offspring of a vice. 

From the consideration of the epulides as described, we proceed 
to that of forms, all of which experience will assure us are best es- 
teemed, and with most benefit and promise to the patient treated, as 
belonging to the second class: the author so treats them because, 
while they may not all express a vice, he cannot prove that they do 
not. By treating them with the latitude given to cancer, nothing 
detrimental to an innocent growth is done, but everything possible, 
with our present knowledge, should the disease be cancer. This 
practice the writer himself shall continue to pursue — finding in it the 
commendation of his highest intelligence — until the typical some- 
thing is discovered which shall allow him to know a cancer in all its 
expressions, just as to-day one might not easily be deceived in the 
hernias or ranulas. 

The Epulides not Self-explaining. — We pass now to that 
consideration which includes every other epulic tumor which may 
be met with in the mouth : histologically, we would class these as 
myeloid, sarcoid, myxoid, fibroid, scirrhoid, encephaloid, etc. ; clin- 
ically, we are not concerned to give them any name : the single con- 
cern with our classification being as to the self-explainability or non- 
explainability of a tumor. With the epulides the author has had 
much to do ; he may be pardoned for suggesting that perhaps few 
in this direction have had wider opportunities of observation ; and, 



826 ORAL DISEASES AND SURGERY. 

as the result of such an experience, he believes that he advances the 
highest truth, and that which will be found to redound to the greatest 
good of a patient, when he teaches that that is to be called, vieived, 
and treated as cancer which cannot be proved not to be cancer* 

Cancer is treated in consideration of a twofold expression belong- 
ing to the condition. When infiltrated, that is, when parts adjacent 
to a tumor seem to be in marked sympathy, being engorged and 
shading dimly away into the healthy structure ; when glands are 
indurated and dyscrasia is marked; then, not knowing any antidote 
to the virus, a surgeon can do nothing for a patient. When, on the 
contrary, a cancer expression is strictly localized, when a tumefaction 
does not shade gradually away, but possesses a strict individuality, 
like the concentric fibroid, — a spindle-celled, or even a giant-celled, 
sarcoma, — then, let it be epulic, or wherever situated, ablation is 
indorsed, on the principle of assistance rendered to a something 
which offers its highest expression of attempt to help itself. 

Thus, accepting the premises, we are to find in the character of an 
epulic tumor the practice pertaining to it. It would seem impossible 
for indecision or confusion to exist ; only may it pertain to the con- 
science of the surgeon to be certain that he keeps pace with the 
diagnostic intelligence of his age. 

Presenting Figs. 252-256 as illustrations of some of the various 
expressions of the epulides, attention may be directed, with benefit 
to many, perhaps, to a description of the cases, together with the 
practice adopted, and the results. 

Case, Fig. 252. — Some four years ago, Mrs. T., the sister of a 
medical friend, was brought by her brother to my office for consultation 
on a tumor (about the size of an ordinary pea) growing from the 
alveolus of an upper molar tooth. I thought this tumor belonged 
to the class pulp-fungoid. There was the broken palatine fang in 
the jaw, but so deep as to be only fairly discernible to the probe ; I 
could not see the origin of the growth, but inferred its character; 

* The author of course sees that here are involved the learning, experi- 
ence, and judgment of an observer. But with all grades of experience, he 
must perceive his position equally to hold. A man can handle and treat 
a matter only as he comprehends it; it is the fatal misfortune of all cancer- 
afflicted patients that the highest intelligence has not yet arrived at the 
apprehension of what cancer is. It is a great misfortune for a patient to fall 
into the hands of a practitioner who does not know — to the extent of the 
known — what is not cancer. 



TV MORS OF THE MOUTH. 



827 



and, by separating carefully the alveolus from the fang, I was en- 
abled, after some little trouble, to get the root from its bed. The 



Epultc Tumors. 



Fig. 252. 




Fig. 254 a. 




Fig. 255. 




Fig. 253. 




Fig. 254 6. 




Fig. 256. 




little tumor proved to be an outgrowth of the periodonteal membrane, 
and not an excrescence from the pulp ; ia character it was distinctly 



828 ORAL DISEASES AND SURGEBY. 

and decidedly fibrous, — it was, then, histologically classifiable as an 
epulo-fibroid tumor. It did not look like a growth from the periodon- 
teum, but rather as if its origin was in the crusta petrosa, and it had 
carried the membrane before it, somewhat as the infundibuliforrn 
fascia is made a tunic to the descending intestine in an oblique inguinal 
hernia. The removal of the fang brought the growth cleanly away. 
Of course, no scraping or cutting of the parts was necessary : the 
growth was evidently an emanation of the dental aspect of the 
periodonteum, and had in no way involved its alveolar reflection. 
jSTo treatment of any kind outside of the removal of the tooth was 
employed. The patient' remains perfectly cured. This is the only 
growth of just such relations that I have ever met with. 

Case, Fig. 253. Epulo- Erectile Tumor. — Mrs.- J. presented herself 
some time in 1862, with a livid, threatening-looking tumor, the size 
of a hickory-nut, occupying the left alveolar face of the upper jaw, 
extending from the lateral incisor back to near the tuberosity. This 
tumor diminished in size during sleep, and increased during the 
time of any excitement which tended to accelerate the circulation, 
sometimes seeming like a solid body, at other times like a spongy 
mass ; it was evidently erectile in its nature, analogous to the 
ordinary naavi. It was an epulo-erectile tumor. 

Separating the growth from the gum, its association with the 
periosteum was plainly evident; and the probe revealed extensive 
involvement of the neighboring bone. An operation, which resulted 
in complete cure, was performed as follows : the lip being held well 
out of the way by au assistant, an incision was made, extending 
from the central incisor tooth of the affected side back to the tuber- 
osity, a similar cut being carried back on the palatine face of the 
tumor to the place of beginning : these cuts were made freely through 
the soft parts down to the bone, and completely circumscribed the 
tumor, with a reasonable margin to spare. The central incisor was 
next extracted, and, with the ordinary cutting-forceps, a cut was 
made through its alveolus, extending almost to the labio-nasal angle. 
A second pair of cutting-forceps was now taken up, and, by two cuts 
the width of its blades, the involved bone was removed ; the section 
extending, as is evident, from the situation of the left central incisor 
to the tuberosity. Considerable hemorrhage attended the operation, 
although the section was well outside of the vessels involved, three 
ligatures being required. Treatment by excision of the bone was 
here necessitated from the implication of that tissue. 

After- Treatment. — The lady being of very full habit and of mark- 



TUMORS OF THE MOUTH. 829 

edly sanguine temperament, magnesiee sulph. ^ss was ordered the 
evening of the operation. As an opiate, morph. sulph. gr. ss. 

Day after Operation. — Marked inflammatory action, attended with 
considerable swelling of the tissues of the face. 



"o 



R. — Plumbi acetatis, 3ij ; 
Tincturse opii, §ij ; 
Aquae, §xvj. 

Ordered a cloth wet with this preparation to be kept continuously 
upon the face. 

Third day. Inflammation increasing ; eyes completely closed from 
the great oedema of the lids ; mag. sulph. reordered, together with 
hot pediluvia; eyelids heavily painted with tincture of iodine. 

Fourth day. Erysipelas set in ; the face looking like a glistening 
red ball ; patient restless, nervous, and frightened ; painted the 
whole face with tincture of iodine, officinal strength ; the lead-water 
and laudanum continued ; iron and quinine internally.* 

R. — Tincture ferri chloridi, 3"j ; 
Quiniee sulphatis, gr. xxv. 
Sig. — Fifteen drops in water every three hours. 

Also a diaphoretic : 

R. — Liquoris amnionic acetatis, ^ij. 
Sig. — Tablespoonful every ten minutes until the induction of pro- 
fuse perspiration. 

Sixth day. Erysipelas evidently yielding ; iron and quinine ; paint- 
ing with iodine, lead-water, and laudanum, continued. 

Seventh day. Much improved ; the erysipelatous redness gone ; 
skin wrinkling ; patient can see a little from one eye ; continued 
the painting with the iodine, and the application of the lead-water 
lotion. 

Ninth day. Inflammation all gone ; patient quite comfortable ; the 
exposed bone covered with a thin layer of healthy granulations ; case 
progressing well. 

Twelfth day. Patient attending to household duties ; mouth of 
course very tender, but advancing rapidly toward a cure. 

* The author, for such erysipelatous inflammations, now always employs 
for local use the combination recommended of iron, quinia, and cinchona. 



830 ORAL DISEASES AND SURGERY. 

Twenty-fifth day. Patient may be called well ; needs no further 
attention. 

To complete the case, artificial teeth have been inserted, the plate 
being made to fill up the place of the lost bone. No one would ever 
suppose, in looking at the lady, that she had lost such a portion of 
the jaw. At this writing (1872) the patient remains cured. 

Case, Figs. 254 a and 254 6. — Recurring epulo-fibrous tumor. — 
These two views, from life, represent the case of a young lady as an 
epulic tumor appeared when first operated on, and as it reappeared 
and was reoperated on some four months after the first operation. 

The patient, a young lady of much more than ordinary personal 
attraction, applied for treatment of the tumor as represented in the 
first view. The necessity for an operation having been explained to 
the patient and her parents, I made the following suggestions. First, 
that a section be made which should simply remove the tumor and 
the alveolar process connected with it. If this should succeed, there 
would be no deformity. Second, if the growth should reappear, a 
second operation to be performed, which should remove the bone 
proper, except a simple rim of continuity. Third, if this, too, should 
fail, then the complete section of the bone to be made ; this, of 
course, would be deforming, but it would be the only resource. 
In December, 1866, the first of the operations was performed; the 
bone outside the section looked perfectly 
Fig. 257. healthy, and gave every promise of a satis- 

factory result. In two weeks healthy granu- 
lations had covered the bone, and in one 
month the patient was dismissed cured. 
The following March, however, a small tu- 

Section of bone as first and , , n . ,, /» ,1 

afterward made. bercle appeared m the very centre of the 

site of the original tumor, and in the course 
of three weeks half a dozen new tumors or lobules had sprung up. 
The second operation, as proposed, was now performed, the con- 
tinuity and natural arch of the bone being preserved unbroken. 
This was successful. The patient now (1872) remains perfectly 
well. The site of the removed bone is occupied by artificial teeth ; 
and not the slightest deformity is to be observed. 

Fig. 255. — This figure exhibits a case operated on in 1836 by the 
celebrated English surgeon Mr. Liston. The following is a sum- 
mary of it, given by that gentleman in a paper on " The Tumors of 
the Jaws :" 




TUMORS OF THE MOUTH. 831 

"The patient had labored under the disease for eight years, and 
had been subject to a partial removal of the growth when of in- 
considerable size. The tumor was of fibrous nature as regards its 
disposition, form, and intimate structure. It differed somewhat, how- 
ever, in outward appearance, in consequence of its exposed situation. 
The growth sprang originally from the gums and sockets of the in- 
cisors and canine teeth of the left side ; at an early period it pro- 
truded from the mouth, unconfined and uninfluenced by the pressure 
of the lips or cheek. It had assumed a most formidable size and 
appearance, concealed the palate and pharynx, and gave rise to 
great inconvenience and suffering. The surface had been broken 
by ulceration, but upon close inspection of the projecting part, and 
of that covered by the cheek, it was found to possess a firm consist- 
ence, and to present a peculiar botryoidal arrangement of its parts. 

"An operation proved perfectly successful." 

Case — not illustrated. — Mrs. S., of Camden, N. J. ; epulo- 
fibroid tumor of left superior jaw. This growth was the size of a 
large walnut, the bulging of the cheek quite deforming the patient ; 
growing very rapidly; painless. Patient had been confined with her 
fourth child five weeks before presenting herself. 

Operation. — This was performed three weeks later. The tumor, 
or all that portion of it which was free of the bone, was cleanly 
removed with the scalpel, together with a margin of surrounding 
healthy tissue. This step exposed the bone, which was found 
carious. This was to be removed, which was easily effected by the 
use of the gouge, little by little being cut away until healthy struc- 
ture was exposed. The surgeon recognizes such healthy structure 
both by its feel under the instrument and by its appearance ; healthy 
living bone being white, studded with minute bleeding points. 
Hemorrhage during the operation was considerable, but was con- 
trolled, without ligature, by throwing alum-water into the wound 
from an ordinary syringe. 

After- Treatment. — Yery little required; awash of the perman- 
ganate of potash, five grains to the ounce of water, was given as a 
disinfectant, there being for a few days a somewhat disagreeable 
odor from a decomposing blood-clot. No antiphlogistic or systemic 
treatment of any kind was required, not a bad symptom having ap- 
peared, the patient being entirely well three weeks after the day 
of operation. In this case the floor of the antrum was removed and 
the cavity wholly exposed. At the completion of the cure, it was, 
however, closed up. 



832 ORAL DISEASES AND SURGERY. 

Case — not illustrated. — Mrs. T., West Chestnut Street. Tumor 
of four years' growth ; loose in structure, occupying one-half of the 
roof of the mouth, giving a most disgusting and threatening appear- 
ance. The growth had first appeared between the bicuspid and first 
molar teeth, and at the time of my first seeing it had entirely de- 
stroyed the inner alveolar plate of all the portion of the jaw with 
which it was associated. In raising the tumor from its bed, all the 
underlying palatine process, so far as could be seen, was found to be 
diseased. 

Operation. — This consisted in cutting away with the scalpel as 
much of the growth as possible, and completing the operation on the 
bone with the gouge ; hemorrhage very profuse, the use of a com- 
press being necessary for its arrestation, and this only effected after 
several hours. 

After- Treatment. — Yery little required ; some over-inflammatory 
action, which quickly and readily yielded to low diet for a few 
days, and a single dose of sulphate of magnesia. In three weeks 
the case was in condition to be dismissed. 

These special illustrations, all of them, with the exception of the 
third, being without the pale of our first classification, are given 
because they serve to show that there is an order of fibrous tumors ; 
or, on the other hand, an antagonizing condition of the system, 
which, fully appreciated, would afford to the surgeon an ability to 
prognose the result of operations on them with the same certainty 
as in the removal of a pulp-fungoid. To be able to distinguish this 
class, or species, or condition, would certainly signify a step gained, 
— one of the many steps to be made, without doubt, by those who 
shall come after us. But such ability to distinguish does not yet 
exist. We may infer, but we cannot be certain. 



CHAPTER XL. 

THE TUMORS OF THE MOUTH. 

EXOSTOSIS AND SUBACUTE INELAMMATOBY TUMOKS. 

The term exostosis, as the reader will remember, is derived from 
the Greek words e£, " out of," and oa-tsov, a "bone:" it denotes an 
osseous tumor which forms at the surface of bones, or in their cavi- 
ties ; the first is called exostosis, the latter enostosis. 

The following varieties have been named : "Ivory exostosis, that 
which is ivory-like;" lamina exostosis, that which is made up of 
distinct fibres or layers ; spongy exostosis, that which is like the 
spongy tissue of bone. 

Hyperostosis is precisely the same thing as exostosis, both being 
inflammatory hypertrophies. Inflammatory osseous tumors are 
hyperostoses. 

Because, however, there are great differences in the expressions of 
these conditions, I shall write of them under special heads. 

Exostosis, as commonly met with in the mouth, is 1 strictly benign. 
It is generally recognizable by its extreme slowness of growth, the 
entire absence of pain, — except when it meets with some peculiar 
obstruction, — and its freedom from surrounding disease. It does not 
tend markedly to ulceration, and does not, except mechanically, affect 
the parts even most directly associated with it. 

True exostosis has its origin in local irritation, perhaps always. 
It is true that reference is made by authors to an ossific diathesis, but, 
as is truly remarked by Miller, "A skeleton so susceptible is prone 
rather to the more common inflammatory products of caries, abscesses, 
ulcers, and necrosis." 

That local irritation is the chief cause of exostosis is satisfactorily 
proven, I think, by reference to parts most subject to this interfer- 
ence. The teeth, for example, are found exostosed in a thousand 
instances to one of any other bone, and certainly no bones are so 

52 (833) 



834 ORAL DISEASES AND SURGERY. 

constantly found in irritative conditions. I use the term "bone," 
reminding the reader that the portion of the tooth which takes on 
this morbid action is almost in every proper sense true bone. 

Xon-specific exostosis, occurring on any portion of the maxillary 
bones removed from the alveolar borders, is an exceedingly infrequent 
affection. With every opportunity for observation, I am surprised 
at the fewness of the cases I have seen ; and these, with a very few 
exceptions, have been small, and of little consequence. 

Around the base of the alveolar processes, however, and particu- 
larly on the lingual aspect of the lower jaw, this affection, in a minor 
form, is exceedingly common ; certainly I have seen hundreds of 
examples, the enlargements varying from the size of a small shot to 
that of a rifle-ball. As pathological relations are concerned, they 
seem of little consequence ; I never knew one to result in any harm ; 
and the treatment I have adopted in such cases has been commonly 
the very simple one of letting them alone. 

It is not improbable, though, that cases may present when opera- 
tions seem demanded. I have felt called to operate upon some two 
or three of such as I have met with. The mode of procedure is 
simply to lay off from the tumor the soft parts, and, with a chisel, 
cut away the mass ; there is no hemorrhage or other trouble attend- 
ant on the operation. (See Hyperostosis.) 

Exostosis of the fangs of the teeth — exostosis dentium, the usual 
seat of the disease in the maxillary regions — finds location both in 
the cemental and dentinal structures of these organs ; for while I 
have seen two or three cases where the crowns of the teeth were 
enlarged, as if from a species of exostosis or hypertrophy, yet these 
were so anomalous that I may describe the growth as being asso- 
ciated exclusively with the fangs ; and even here, I think, it will be 
found in the majority of instances confined mostly to the apex, 
growing, bulb-like, as it were, about the end of the root. 

The diagnosis of exostosis in these situations is not always with- 
out confusion. The most frequent pathognomonic feature, however, 
is a sense of continued uneasiness about the parts, not generally 
amounting to pain, but serving as a constant reminder of the pres- 
ence of the tooth. The tooth itself may or may not be carious. 
Pressure, or the stroke of an instrument, does not, in ordinary cases, 
either increase or diminish the soreness ; the sense of fullness about 
the parts is particularly observed where the absorption of the alveo- 
lus is not proportionably active with the exostosis. In these latter 
cases, the extremest symptoms of neuralgia are not unfrequently 



TUMORS OF THE MOUTH. 835 

produced, and, if not comprehended, are of course treated without 
avail. 

One of the most remarkable cases of dental exostosis on record is 
related by Mr. Fox. The subject was a young lady, who, at the 
time she sought the professional aid and advice of this practitioner, 
had suffered so severely and so long that the palpebrae of one eye 
had been closed for nearly two months, and the secretion of saliva 
had for some time been so copious as to flow from her mouth 
whenever it was opened. She had tried every remedy which had 
been recommended by the ablest professional advisers, without de- 
riving any permanent benefit, and was only relieved by the extraction 
of every one of her teeth. 

The surgeon may infer from the mention of this case that- he is 
likely to meet with many gradations of the trouble. The cure will 
consist in the removal of the affected member : this, after the diag- 
nosis, is always easily accomplished w T ith the aid of a pair of cutting- 
forceps. 

Warty Teeth. — In this association reference may be made to an 
anomalous confusion and development of teeth-germs to which the 
term warty has been applied. TTp n another page we shall discuss 
them under the aspect of dentigerous cysts. The rarity of these 
warty teeth permits few the opportunity of seeing them. Among 
the recorded examples are four by S. J. A. Salter, one by Mr. John 
Tomes, two by Wedl, two by M. Oudet, two by M. Forget, and 
one by Mr. Harrison. 

To teeth of such anomalous development M. Broces has applied 
a name that has now come into general use, namely, odontomata. 
These he, with all propriety and clinical justice, has classified into 
circumscribed and diffused, — the first including all masses in which 
recognition of the tooth exists ; the second, those where it is lost 
in an anatomical confusion of the structures. p IQ 2 5g 

The odontoma described from the practice of 
M. Forget, on a succeeding page, constitutes 
the most marked example of the latter on record. 
Fig. 258 is an example of the former. Examples 
of the circumscribed odontomata are given on 
Plate L, Subfigs. 1 and 3. 

A form of dental exostosis termed by Mr. 
Salter the enamel nodule exhibits a pearl-like 
excrescence growing from a tooth. Excrescences of this kind are 
considered to be essentially submerged cusps, being composed of a 
cone of dentine enveloped by a cap of enamel. 




836 



ORAL DISEASES AND SURGERY. 




As an illustration of extreme dental hypertrophy, combined with 
the existence of an enamel nodule, attention may be directed to a 
specimen belonging to the Philadelphia Dental 
Fig. 259. College, exhibited in Fig. 259. This mass is two 

and a half inches in length by two and five-eighths 
inches in circumference; it was associated w r ith the 
roots of a left superior molar, and was extracted 
from the mouth of a laborer by S. H. Whitman, 
of Newport, Perry County, Pennsylvania. 

In examining this specimen, it is observed that 
to the right of the palatine root, and connected 
with it, is a portion of enamel ; being an out- 
growth, as has been inferred, either of a wisdom 
or of a supernumerary tooth, — most likely, how- 
ever, a production of the tunica propria of the tooth itself. Mr. 
Salter describes such cusps as being clothed with a pulp, — the 
enamel pulp. 

A microscopical section of this growth is figured (Fig. 260) 
and described by my friend Dr. J. H. McQuillen, through whom, I 
believe, the specimen was received by the museum: 

" A first or outer section presented only the lacunae and canaliculi 
characteristic of cementum. A second cut differed somewhat from 

this, in having, in addition, certain 
spaces of no definite shape, and ap- 
parently being the blending of a 
number of the lacunas. In a third 
section the lacunae were quite numer- 
ous, and the canaliculi starting from 
them were of considerable length, 
and pursued a tortuous or curved 
direction, resembling very much the 
appearance and course taken by the 
dentinal tubuli in secondary dentine. 
Fig. 260 is from a drawing as seen 
under the microscope. A few canals 
(cut transversely), evidently for the passage of blood-vessels, were 
observed, but no Haversian canals, as in bone, with the lacunae and 
canaliculi arranged in concentric la vers around them." 




In the venereal, scorbutic, and tubercular hypertrophies or exos- 
toses of the maxillarv bones, the features of the common disease 



TUMORS OF THE MOUTH. 837 

become quickly evident in the local trouble ; so remarkably so, 
indeed, that no one would be likely to misunderstand things, pre- 
supposing the general disease to be understood. The growths 
are rapid, painful, and almost always more or less amenable to con- 
stitutional treatment. 

Scrofulous and scorbutic tumors differ from the venereal in being 
more loose and spongy in structure, and, in consequence, more apt 
to run into abscess, being possessed, as it were, of elements for their 
own destruction. 

In these forms of maxillary disease, the lesion is commonly 
heralded by deep-seated, dull pains, which precede by some time 
the visible enlargement of the part. After the tumefactive process 
sets in, it goes on, if uncombated, until the parietes of the bone 
are completely disparted. Associated with this enlargement is an 
unhealthy condition of the soft parts. 

As the disease advances, the centre of the tumor softens, while 
the character of the pain changes, becoming sharp and throbbing ; 
as pus forms, sinuses are created, and thus ulcerations occur on the 
face of the tumor. Enlargement of the maxillae from these causes 
is, however, very uncommon, and might only escape being con- 
founded with cancer by observation of the association with the 
disease at large. 

The treatment of inflammatory tumors of these and similar types 
is to be conducted in consideration of their twofold requirements. 
The systemic influences are to be corrected, while, locally, I think I 
am justified in asserting that, as a rule, they will succumb to the 
treatment commonly directed against similar abscesses of the soft 
parts. I have great confidence in the use of tents and stimulating 
injections. 

There is a simple inflammatory tumefaction of the maxilla some- 
times met with, which might be mistaken for specific exostosis. 
It is to be distinguished, however, by the greater rapidity of the 
swelling and by the greater soreness attendant on it; it comes 
as a cold in the head, or on the chest, — without, in the majority 
of cases, the patient being able to assign any cause, — and it is 
found soon to give way to the same class of antiphlogistics. This 
tumefaction is extra- rather than intramaxillary ; it is simply a peri- 
osteal exudate, and has, of course, no constitutional associative lesion. 

In this connection, attention may be directed to a form of tumor 
frequently found in the mouth, which, clinically, is classible with 
the exostoses. I allude to an apparent expansion of bone fre- 



838 ORAL DISEASES AND SURGERY. 

quently found in association with a strumous diathesis, and so in- 
variably in connection with periodonteally diseased teeth or roots 
of teeth ; not always, however, are these expansions or growths in 
association with the strumous condition, as I have treated them in 
individuals whose constitutional condition seemed perfect. 

These tumors have a common history. The nerve of a tooth dies, 
and the periodonteum takes on a chronic irritative condition, or per- 
haps a tooth has been fractured in attempts at extraction, and the 
root, or some portion, has been left in the socket. After a time, 
sooner or later, a slight swelling, apparently of the gum, is ob- 
served. This may readily be taken for a chronic alveolar abscess ; 
there is no pain, however, associated with the enlargement, which 
is soon seen to differ from the abscess in the slowness of its 
evolution ; it is also hard, and perfectly unyielding under pressure. 
As we watch the case, month after month, we find it gradually 
to grow, giving to the observer the impression of an expansion of 
the bone under the gums, although, as we understand, there are 
no special or marked signs of such cystiform condition. If we pass 
an exploring-needle into the tumor, it feels as if it were cutting its 
way through spongy bone ; and so indeed it is, as dissection will 
reveal to us that the cancellated structure has taken on hyper- 
trophic action, and it is such spongy enlargement that bulges out 
the overlying parts and makes the tumor. I have treated quite a 
number of these growths, and invariably in connection with the in- 
ferior jaw. I do not think they would often be found in the superior, 
such chronic conditions being here more apt to induce caries, which 
disease we know to be as uncommon to the lower as it is common 
to the upper jaw. These tumors, so far as I have seen them, either 
remain fixed in character, after growing to the size of half a walnut, 
or, in very bad subjects, they degenerate into abscess, and, dis- 
charging thus the offending body, cure themselves. Such sponta- 
neous cure is, however, not common. 

The surgical treatment of these tumors is both simple and 
effectual. It is enough, not unfrequently, to remove the tooth or 
root, particularly if, in connection with such removal, we keep the 
socket open for a few weeks with a tent of cotton or sponge. A 
very certain method, and one which I am in the habit of employing 
in my own practice, consists in cutting away, with a delicate 
gouge, the enlarged mass : this is easily accomplished by using the 
opening made in the extraction of the tooth as a means of ingress to 
the mass ; it can in this way be cut out, piece by piece, without any 



TUMORS OF THE MOUTH. 



839 



external incision, and with a wound not larger than that made by 
the preliminary extraction. After such operation the parts are to 
be well syringed, and a tent kept in the tooth-socket, to insure 
granulations from the circumference of the wound. In two or three 
weeks the cure will commonly be found complete. 

In this connection attention may be directed to an obscurity 
which sometimes exists in the diagnostic relationship of diseased 
teeth, — that is, no teeth or roots of teeth may seem to be present. 
A sufficiently close observation, however, will always detect in the 
neighborhood a fistulous opening ; it may be very minute, but it is 
seldom, if ever, absent. If a probe be passed into this orifice, it will 
lead to the offending agent. 



Fig. 261. — Hyperostosis. 



HYPEEOSTOSIS. 

In connection with the simple tumors, reference may now be 
made to general facial hyperostosis sometimes existing. In a 
work published by Mr. Heath, being the Jacksonian prize essay for 
1867 of the Royal College of Surgeons, England, the following 
illustrative diagram and description of a case are given : 

The patient, when about forty-five years of age, and apparently in 
perfect health, was exposed to a cold wind ; immediately after which 
he perceived an itching and heat in his eyes, and swelling of the 
face rapidly supervened. A small tumor formed just below the 
inner angle of each eye, which burst, 
and after twelve weeks he was able 
to resume his employment. He suf- 
fered from inflammatory attacks in 
the tumors, with much pain in the 
head on more than one occasion, and 
consulted many medical men ; but 
no treatment relieved the disease or 
retarded the growth of the tumors, 
which increased slowly and were of 
stony hardness. The eyes were pro- 
jected from the orbits by the tumors, 
and the right eye inflamed and burst, 
while the left was accidentally rup- 
tured by a blow. The patient lived 

to over sixty years of age, and died of apoplexy, having been occa- 
sionally maniacal during the last two years of life. The portrait is 
taken from the work of Mr. Howship ("Practical Observations on 




840 ORAL DISEASES AND SUBGERY. 

Surgery"). The skull of the patient is preserved in the College of 
Surgeons, and shows, as might be anticipated from the portrait, two 
large masses of almost exactly symmetrical form and arrangement, 
which have partially coalesced in the median line. The growths are 
as hard as ivory, and consist of very close, cancellous structure. 
They project more than three inches from the face, and an inch be- 
yond the malar bones on each side. The man attributed the growths 
to repeated blows received on the face in fighting. 

The skull of a Peruvian (3093, College of Surgeons, London) is 
also alluded to by this same author. In this case the disease is of 
a more diffused character, all the bones of the face, as well as the 
frontal and the adjacent parts of the sphenoid and parietal, being 
enlarged and thickened in a remarkable manner. The nasal fossae 
and orbits are nearly closed, the superior maxillary bones having 
grown into great knobbed and tubercular masses, in which their 
original form can hardly be discovered. The hard palate is similarly 
diseased. The lower jaw is enormously enlarged at its right angle, 
and in the greater part of its right half it measures upwards of five 
inches in circumference, and all but three of its alveoli are closed up. 
A section of the lower jaw shows that its interior is composed of an 
almost uniformly hard and compact, but finely porous, bone. There 
is no history attached to the specimen. 

Hyperostosis is simply exostosis or enostosis. It is analogous to 
hypertrophy of the soft parts, and must have a similar history. 

As can be very well understood, varieties in form and character 
present themselves. These growths are sometimes associated ex- 
clusively with the face of a bone, as in the ordinary exostosis. In 
these cases the periosteum may separate the two bodies. In other 
cases there is hypertrophy of the bone proper. The condition is 
one of disease only as there is a lack of correspondence in other 
parts. Any section of a hyperostosed part exhibits the peculiar 
features of bone-substance ; it may be, as is often seen, that the 
cellular substance is compressed and much altered, but there is the 
distinction to be observed between it and a cortical boundary, and 
the analysis remains the same, — that is, as the constituent parts 
are concerned. When these hypertrophies associate exclusively 
with the endosteum, as in long bones, they obliterate or diminish 
the medullary canal, and, if of sufficient size, expand the external 
parts into a tumor, greater or less in size. 

The history of any form of hyperostosis is the history of certain 
of the phenomena of inflammation ; there is, from some cause or 



TUMORS OF THE MOUTH. 841 

other, irritation attended with vascular changes, the effusion of 
plastic matter associated with osseous transformation. What this 
source of irritation is, and how to control it, are matters which 
necessarily invite the attention of the surgeon. 

Reference has been made on a preceding page to the hypertro- 
phies of the specific conditions ; such enlargements are easy enough 
to understand, even if not so easy to remove. But the hyperostoses 
here considered are not of such character, but seem to be of an 
entirely local signification; hence a local source of offense may not 
be sought for in vain, as, for example, in Mr. Howship's case, 
where the ostitis might very plausibly be attributed to the blows 
received. The inflammatory thickening of bone, alluded to a few 
pages back in connection with diseased teeth-roots, is bat another 
exhibition of the results of local irritation. 

That the hyperostoses are to be viewed, and in every way treated, 
as simple overgrowths, is certainly well exhibited by Mr. Quekett, 
who, submitting to microscopic examination portions of all the 
osseous tumors in the Royal College of Surgeons, confirms the 
position in all particulars. The rates of the growths of such 
tumors are, I presume, influenced by individual susceptibilities or 
peculiarities; there is certainly in this respect the greatest possible 
difference. In the Osteographia of Mr. Cheselden is an engraving 
of an osseous tumor surrounding the head of a tibia, which measures 
exactly one yard in circumference. An imposing growth is also 
figured in Mr. Paget's Surgical Pathology. 

In this latter case, as Prof. Clark describes the tumor, the hardest 
parts have neither Haversian canals nor lacunas. In the less hard 
parts the canals are very large, and the lacunse are not arranged in 
circles around them, and everywhere the lacunas are of irregular or 
distorted form. 

A remarkable specimen of an osseous tumor of the left upper 
maxilla (Fig. 262), from the Traite de Pathologie Externe, found in 
the Musee Dupuytren, is described in Mr. Heath's essa}^ as being 
limited behind by the pterygoid process, internally by the intermax- 
illary suture, above and externally by the malar bone. The tumor 
encroaches considerably upon the cavity of the mouth, and reaches 
back as far as the front of the spine. Its form is bilobed, and in the 
deep sulcus between the lobes can be seen a molar tooth. All the 
other teeth of the jaw have disappeared, and there is no trace of 
their alveoli. The left orbit and nasal fossa are not sensibly dimin- 




842 ORAL DISEASES AND SURGERY. 

ished in size, but the cavity of the mouth is almost entirely occupied 

by the posterior lobe of the tumor. The lower jaw has, in this 

-n o^o ^ m case, undergone several remarkable alter- 

Fig. 262. — Osseous Tumor. ' ° 

ations. It must at first have pressed 

upon the growth and produced the deep 
sulcus between the lobes ; but in its turn 
the tumor has reacted upon the lower 
jaw with the following- effect: it has 
caused a double luxation of the jaw, the 
left condyle resting against the root of 
the zygoma, and the glenoid cavity being 
filled with soft material. The teeth of 
the left side of the lower jaw have disap- 
peared, and absorption of part of the 
coronoid process and the whole of the 
alveolus has taken place, so that only the base of this part of the 
bone is left. The outer surface of the tumor is smooth, and presents 
numerous vascular grooves of good size ; at many points it is per- 
forated with holes. The vascularity of the other bones of the face 
does not appear to be augmented. 

In Guy's Hospital Reports a case is described by Mr. Hilton in 
which a tumor similar in signification to the one just referred to 
spontaneously separated from the face. The patient was a man 
aged thirty-six, who, twenty-three years before Mr. Hilton saw him, 
noticed a pimple below the left eye, close to the nose, which he irri- 
tated, and from that spot the tumor appears to have originated. 
The tumor, in its growth, displaced the eyeball, giving rise to 
excruciating pain, which subsided on the bursting of the ball. It 
began to loosen by a process of ulceration around its margin six 
years before it fell out, which event was unattended by bleeding or 
pain. The tumor weighed fourteen and three-quarter ounces. It 
was tuberculated externally, and an irregular cavity existed at the 
posterior part. A section presented a very hard, polished surface, 
resembling ivory, and exhibited lines in concentric curves, enlarging 
as they were traced from the posterior part. The huge cavity left 
by the tumor was bounded below by the floor of the nose and 
antrum, above by the frontal and ethmoid bones, internally by the 
septum nasi, and externally by the orbit, which had been consider- 
ably encroached upon by the tumor. 

Among several rare and interesting cases in this direction, which 
from time to time have been under the observation of the author, 



TUMORS OF THE MOUTH. 



843 



particular mention might be made of a lad, William Mars, born 
with a general enlargement of the whole left side of the face, — 
cheek, jaw, teeth, tongue. As the boy grows, so in a relative pro- 
portion enlarges the left side. The exact mesian line of distinction 
is curious to observe : the left side of the tongue is quite one-third 
larger than the right, the papillae likewise showing the distinction. 
Commencing with the left central, the teeth are also one-third larger 
than are their fellows of the opposite side. The ears, also, differ in 
size. No sense of discomfort is experienced by the patient. This 
congenital peculiarity is confined strictly to the head, all other parts 
being in correspondence. 

The cut of a case of osseous hypertrophy — being the exact dupli- 
cate of an impression in plaster in my own possession, taken by a 
practitioner of a distant county, in whose own mouth the tumor 
exists — is kindly sent me by D. H. G-oodwillie, M.D., of New York, 
the following description accompanying: 



Pig. 263. — Hyperostosis of Tuberosity of Maxilla. 




" Osseous Tumor of the Bight Superior Maxillary. — Mrs. B., 
aged forty-four years, has always enjoyed good health. About six 
years ago she noticed that the alveolus of the right superior maxil- 
lary began to enlarge, and has gradually increased to the present 



844 ORAL DISEASES AND SURGERY. 

time. In size and shape it very much resembles a hen's egg, the 
large end presenting posteriorly. It extends antero-posteriorly from 
the right superior canine to the internal pterygoid process, laterally 
from near the centre of the palate to the maxillo-malar fossa, for- 
ward to the canine fossa, and to a slight degree into the antrum of 
Highmore. 

" The mucous membrane over the surface of the tumor appeared a 
little lighter in color than normal ; this, no doubt, was due to the 
tension on it by the parts below. In the surface of the tumor could 
be seen the fangs of the first and second molars. The canine and 
bicuspidati were not decayed. First bicuspis and canine retained 
their normal position in the jaw, but their crowns were somewhat 
buried in the tumor. The crown of the second bicuspis could all 
be seen above the surface of the tumor, but the whole tooth was 
raised out of its natural position, and thrown inward about one- 
half an inch. One of the roots of a molar was lying longitudinally 
in the soft parts on the surface of the tumor. 

" She has experienced no pain, or discharge from the mouth or 
nose, during the long period of its growth ; from its apparent firm 
texture, together with the excellent health the patient has always 
enjoyed, there appears no doubt of its benignant character. 

" Pathological Appearances. — On making a section of the tumor 
through the longitudinal direction of the teeth, there was to be seen 
the following : At the apex of the second molar tooth there was a 
small, soft cyst, containing some pus, and for a short distance sur- 
rounding this the bone appeared quite cancellated, but the rest of 
the tumor was quite dense in structure. 

" The pulp of the canine and first bicuspis had still some vitality, 
but that of the second bicuspis was dead. The pulp-chambers were 
decreased in size by a deposit of osteo-dentine to their walls, slight 
hypertrophy of the cementum on the fangs. A large nerve entered 
the tumor on its buccal side. 

" The microscopical examination of this tumor, as made by Dr. 
J. W. S. Arnold, and as shown by his drawing (Fig. 264), is ' com- 
posed of cancellated tissue almost entirely ; the outer edge, of a thin 
layer of more compact bony tissue. In the spongy part is a small 
amount of soft marrow, containing the usual constituents of foetal 
marrow, — i.e. medulla-cells, and myeloplaxes with oil-globules.'" 

Exostosis, or, more correctly speaking, hypertrophy of the tubes 
of the maxillary bone, is a quite frequent affection, being associated, 
as the author infers, with the continuous excitability engendered in 



TUMORS OF THE MOUTH. 



845 



this part by that elongatory process which terminates only in adult 
life. The propriety of operating upon these cases is to be deter- 

Fig. 264. 




mined by the individual conditions. Many of such tumors may 
safely be let alone, exhibiting little or no change from year to year. 
Associated with such hypertrophies the author has met with neu- 
ralgia of such severity that only through section of the affected 
part could relief from suffering be procured. 



CHAPTER XLI. 

THE TUMORS OF THE MOUTH. 

SELF-EXPLAINING CYSTIC TUMOES. 

The self-explaining cystic tumors of the jaws are, all of them 
dental : of this the author is now entirely satisfied. In the former 
edition of this work* these cysts were described as being of two kinds, 
simple and compound : the first, the simple cysts, were alluded to as 
mere expansions of the outer plate of the bones, — wind-bags, as the 
older writers called them. The second class, the compound, were 
described as cysts containing peculiar contents, which contents 
induced the cysts and constituted the lesion to be studied; such con- 
tents being teeth in a state of full or partial or anomalous develop- 
ment, the tumor being the odontocele, or, as it might as well be 
termed, the dentigerous cyst. 

The Simple Cyst. — All writers on surgery have remarked the 
existence, in the mouth, of this form of tumor, — a simple expansion of 
the bone, with varying fluid or gaseous contents. Different authors 
differently describe and name them. The term spina ventosa is, 
perhaps, about the most unmeaning that has been applied. As the 
author knows them, their history may be written as follows: there 
is first remarked on the side of the jaw, either superior or inferior 
(no preference seems to exist), a slight flattened enlargement; this 
increases slowly, until the swelling reaches the size of half a hickory- 
nut; they are seldom seen larger. No pain attends the growth, 
and, outside of the mental disquietude necessarily induced, no func- 
tional or other constitutional disturbance attends. The slowness of 
growth is such that it may require from one to three years to reach 
the size alluded to. This tardiness, absence of pain, and constitu- 
tional disturbance form marked diagnostic signs. Another sign, 
and one on which most writers lay particular stress, is the giving 
forth, on pressure, of a parchment-like crackling ; with this last the 

* Diseases and Surgery of the Mouth, Jaws, and Associate Parts. 
(846) 



TUMORS OF THE MOUTH. 847 

writer seems, however, to have had a peculiar experience, for, while 
he has treated quite his share of such cases, it has not been his 
fortune to find such crackling sound in any one of them, and 
while of course it would ill become any individual to assert that 
such a crackling never can be heard, yet it is to be impressed that 
such a sign is not by any means an ever-present indication, conse- 
quently is not to be given the heed demanded for it. In most of 
these tumors, septi, more or less in number, have been found sup- 
porting the vault; with the presence of such pillars, it is plain 
enough that yielding would be out of the question, so that the 
practitioner is not to be deceived by the firm character of the tumor. 
The gum covering such cystic tumors is always perfectly normal, — 
no congestion, nothing indicating its implication ; a matter impor- 
tant to observe, as, should the diagnosis be in any wise obscure, the 
practitioner would have at least the satisfaction of feeling a toler- 
able assurance as to the benign character of the growth as well as 
to its non-acute character. 

Of the number of cysts of this class treated by the author, every 
one has been situated in the outer or vestibular walls of the bones. 
Why they should have been so, or indeed whether it is always the 
case, he does not know. An individual experience alone is offered. 

A diagnosis made out, the cure is very simple. A common treat- 
ment, and one generally practiced, because of its little trouble, is to 
make a crucial incision through the body of the tumor, and, break- 
ing up such septi as may exist, stuff the cavity with lint saturated 
with the tincture of iodine : this, if there be no foreign body in the 
cavity, as, for instance, the root of a dead tooth, will invariably 
cause the base to throw out granulations, and thus obliterate the 
cyst. 

Another mode, not unfrequently resorted to, is to dissect from the 
tumor, in flap-form, the overlying gum, and with a chisel cut away 
the vault of the cyst ; the parts are then carefully syringed and the 
flap laid back. This latter operation requires much more time, much 
more skill, and gives much more pain. The first is not nearly so 
objectionable to the patient, and is equally effectual. 

Concerning hemorrhage, little anxiety need be felt. It is seldom 
found to give any trouble ; it may be necessary to syringe the cavity 
with a little alum-water, or some other astringent, but even this is 
not commonly needed. 

Case. — Mrs. C, aged about twenty-one, applied to the author, 
some two years ago, for treatment of a tumor occupying the canine 



848 ORAL DISEASES AND SURGERY. 

fossa of the left superior maxillary bone. The growth had been 
eighteen months in progress ; was about the size of half a walnut, 
perfectly solid to the touch, painless, and entirely healthy-looking ; 
the greatest disquietude of the patient being mental, her mother 
having died from scirrhous cancer. 

Diagnosis. — Simple cyst. 

Treatment. — Crucial incisions were made ; several delicate septi 
of bone, which the cuts revealed, were broken up ; the cyst was 
injected for the first three days with weak stimulating liquors. No 
inflammation developing, tufts of cotton were saturated with tinc- 
ture of iodine, and the cyst stuffed with them. In one week the site 
of the cavity was occupied by healthy granulations ; in three weeks 
the patient was entirely cured, and left the city for her home in an 
adjoining State. 

Case. — About nine months back, a German woman applied with 
a cystic tumor, similar to the above ; it was certainly as unyielding 
as solid bone. This tumor was treated by making a crucial incision 
through the soft parts alone ; the flaps were then dissected off, and 
the cyst, being exposed, was cut away with a chisel-shaped instru- 
ment. The flaps fell naturally into the cavity, and were left, even 
without a stitch, to take care of themselves. The cure was com- 
plete in about a week. 

The above constituted the description and the illustrations offered 
of the simple cysts; but in the mind of the writer there existed a 
degree of confusion, because in some of these cysts nothing was 
found, and a tumor strictly local, as these always prove to be, 
should not be without local explanation. This explanation the 
author has now found in an enlarged experience, in which, in every 
individual instance over which he has extended his inquiries, he 
has been able to demonstrate entirely an origin of the cysts in 
dental disease. Close observation in most of them will discover 
some mere particles, it may be, of an unabsorbed tooth-root, a re- 
trograding metamorphosis, fully explaining an empty condition of 
this cyst, which later would necessarily have been met with.* 



* There is a tumor of the soft parts of the jaw — cystic, but not osseous — 
which must not be confounded with the class just described. Both look, occa- 
sionally, precisely alike, but the latter yields under pressure, as any semi-soft 
tumor would yield. Mr. Paget alludes to such a disease in his lectures on 
Surgical Pathology, pages 342-3. "A woman/' he says, " thirty-eight years 
old, was under my care in 1849, in whom, at first sight, I could not but suppose 



TUMORS OF THE MOUTH. 

The odontocele proper is exhibited in Fig. 265. 
*In the diagram a large tumor is recognized to have existed in the 
body of the lower jaw, cystic in character, as seen by the sections, 
the exciting lesion of which, b, a tooth-crown, is seen lying in the 
cavity. 

The diagnosis of an odontocele may seldom be a matter of doubt. 
The form here presented is the subject in its simplest expression ; 
from this it varies to the complex dentigerous tumor, an example of 
which is presented on the succeeding pages. 

An odontocele may present itself in any part of the ossa maxillse, 
and, what is of much consequence to be remembered, may have, as 
the lesion of departure, a supernumerary tooth. 

The absence of a tooth or teeth from the arch through non-devel- 



something was distending the antrum, so closely was deformity of the face 
due to such disease imitated. But the swelling was soft and elastic, and pro- 
jected the thin mucous membrane of the gum of the upper jaw, like a half- 
empty sac. I cut into this sac, and let out nearly an ounce of turbid, brownish 
liquid, sparkling with crystals of cholesterine. The posterior wall of the cyst 
rested in a deep excavation on the surface of the alveolar border of the upper 
jaw ; an adaptation of shape attained, I suppose, as the result of the long- 
continued pressure of the cyst, which had existed six years." 

The same author also makes mention of a young man under his care with 
a similar tumor, which, he says, was the result of an injury to the gum or 
alveolar border six months previously. In neither of these cases, he remarks, 
could he find any disease of the maxillary bone. The origin of such cysts, 
so far as the experience of the writer goes, is to be found in a diseased tooth- 
fang. There surely would have been found to be at best one little shot-like 
hole somewhere about the surrounding osseous wall ; at any rate, such is the. 
history as I have met with them. 

A succeeding case, which Mr. Paget mentions, seems to prove the tumors-, 
to be the same as I refer to. " A lady," he says, " had a small cyst of this 
kind, which had existed twenty-seven years, filling and discharging almost 
daily. It had its origin in a blow, by which the two median incisors were 
loosened."* 

A few winters back, a physician from Kentucky applied to the author for 
treatment of a tumor of the lower jaw, which had existed for over two years : 
it had the feel of a fibroid body. This gentleman, with the imaginative 
qualities common to the practitioner when he himself becomes a patient, had 
succeeded in satisfying himself of the cancerous character of his trouble. An 
incision through the growth demonstrated it to be a cold alveolar abscess. In 
a single week he was cured ; the treatment required was, simply keeping 
the incision patulous, and using a few stimulating injections. 



This history is that of chronic alveolar abscess in every particular. 

53 



1 1 ! 



850 



ORAL DISEASES AND SURGERY. 



opnient, conjoined with the presence of a non-vascular tumor, affords 
inference of the existence of odontocele. 

Fig. 265. 




In the case of supernumerary teeth, or of doubt as to absence of 
teeth through non-development, the use of the exploring-needle, 
striking the glossy, slippery enamel, will always explain the ordinary 
condition. 

Illustrations. — A young lady, aged sixteen, presented herself, 
having a tumor, intramaxillary, evidently, occupying the anterior 
left side of the hard palate. Her exact condition was as follows. 
She had never had a single tooth of the permanent set extracted, 
yet she lacked, to make up the complement common to her age, the 
canine of the affected side. The tumor was, of course, an odonto- 
cele, or at least so great was the probability of such being its char- 
acter, considering the absence of the tooth from the dental arch, that 
any surgeon would feel justified in founding a proposed operation 
on such conviction. The exploring-needle verified the conclusion.* 

In 1861 the following very interesting case of odontocele came 
under the observation of the author. The patient, desiring a set of 
artificial teeth, about a year previous, had had all the teeth of the 



* Eefer, for proper appreciation of the subject of encysted teeth, to page 
145, and for diagrams to pages 158, 160, 161, 163, 167. 



TUMORS OF THE MOUTH. 851 

upper jaw extracted, and, as is customary (not desiring to wear a 
temporary denture), had been dismissed for a period of some four 
months. At the end of this time the impression of his mouth had 
been taken, the parts being in a good healthy condition. The teeth 
were made, placed in position, and worn with entire comfort for a 
period of several months. 

About eight weeks before presenting himself, these artificial teeth 
were found to be getting loose, as if from some projection at the 
right border of the myrtiform fossa. Applying to his dentist, sur- 
prise was expressed at the occurrence, and advice given that the 
further progress of the case should be awaited. At this period the 
gums were more or less congested, and were putting on quite an 
angry appearance ; a few days later a fistula formed. His dentist, 
confident that no portion of the roots of any of the teeth had been 
left in the alveolus, now dismissed the case, advising him to seek 
surgical assistance. In this condition he came under observation. 

The case now presented the following features : much engorge- 
ment of all that portion of the gum and lip covering the incisive 
and canine fossae, which engorgement extended in a triangular 
direction to the inner canthus of the right eye, much soreness on 
pressure over all the affected parts, the fistula discharging thin and 
occasionally bloody pus. 

Examination with the probe gave the impression that it struck 
against the root of a tooth, which would certainly have influenced 
the making up of the diagnosis if experience had not suggested 
that no tooth could, under ordinary circumstances, have a fang ex- 
tending such a length. 

Deducing from the conditions present the imperative necessity for 
an exploration, and the patient willingly acceding to the conclusion, 
the following course was pursued. The patient was etherized. An 
assistant, having sponge and water at his side, took charge of the 
lower jaw and lip. A second assistant steadied the head and held 
the superior lip well out of the way of the knife. 

The parts being thus very fairly exposed, a pointed and some- 
what delicate-bladed bistoury was passed from the superior fleshy 
boundary of the canine fossa to the inner canthus. The cut passed 
not only through the soft parts, but, in the return, sunk readily into 
the bone. A first flap was now dissected posteriorly from the dead 
mass : a second was bounded mesially by the nasal bone, ala, and 
left prominence of the myrtiform fossa. The blood being sponged 
away, there was discovered, lying in the very centre of the carious 



852 ORAL DISEASES AND SURGEBT. 

bone, a cuspid tooth of ordinary size and development, the apex 
being in immediate relation with the floor of the orbit. 

That this tumor had existed for a long time is, of course, not to be 
doubted, but it excited the attention of the patient only on the setting 
up of acute inflammatory action. This inflammation soon destroyed 
the integrity of the vault of the c}^st : hence the softened carious 
state in which it was found. The interest associated with the case 
lies in the absence of all the teeth by extraction, and the consequent 
loss of data for the diagnosis.* A tumor precisely similar is de- 
scribed by Dupuytren. 

* " In 1862, 1 published, in the Boston Medical and SicrgicalJournal, a case 
occurring in an elderly woman of a cyst which involved the ascending por- 
tion and condyles of the jaw, and which I removed ; not thinking it safe, in 
a person of her age, when the disorganization of the jaw seemed to be so 
complete, to run the risk of an experimental mode of treatment. Since that 
time, I have had an opportunity of trying the conservative plan of treatment 
in two instances, which I propose shortly to relate. 

" Notwithstanding the principle which has been suggested or hinted at for 
the treatment of large cystic tumors of the jaw, none of the writers on the 
subject have presented cases — where complete destruction of the bone has 
taken place, leaving nothing but a delicate cyst — which have been successfully 
treated by the method referred to. Dupuytren, in his work on 'Diseases of 
the Bones,' gives several cases treated without excision ; some of them, how- 
ever, unsuccessfully. M. Nelaton has also written upon the subject, referring 
for cases to the work of Dupuytren, and advising the puncture of the cyst 
and the stuffing of its cavity with lint. Mr. Erichsen says, ' when the cysts are 
so large that they have destroyed the integrity of the bone, or when they are 
associated with a large quantity of fibrous tissue, so as to constitute true fibro- 
cystic tumors, excision of the diseased bone must be practiced.' Mr. Stanley, 
in his ' Treatise on the Diseases of the Bones,' describes perfectly the affection, 
but does not allude to any other operation than the ' removal of the tumor 
and of the portion of the bone from which it has arisen.' 

" In the two following cases the treatment consisted in the puncture of the 
sac within the mouth, evacuating its contents, and at the same time obliter- 
ating its cavity by crushing in its walls ; and lastly, in keeping up, by injec- 
tions, etc., a sufficient degree of irritation to favor the deposition of new bone. 
The comparative mildness of this mode of treatment, and the excellent char- 
acter of the results, combine to award the preference for this operation over 
excision, or even the large external incision adopted by Dupuytren. 

"Cystic Tumor of the Lower Jaw. Case I, — A young woman, aged twenty- 
five, with light hair, blue eyes, and delicate skin, applied to me, in the spring 
of 1862, on account of a large tumor involving the whole right side of the jaw 
above its angle. The tumor was of a globular shape, extended back under 
the lobe of the ear, forward so as to encroach upon the cavity of the mouth, 
and upward so as to press upon and somewhat to overlap the zygoma. The 



TUMORS OF THE MOUTH. 853 

Osteo-dental tumors dependent on the development of supernu- 
merary teeth are quite common ; they are generally easily recognized 

external surface of the tumor was smooth and shining, slightly cedematous, 
and she suffered somewhat from its pressure upon the surrounding organs. It 
had commenced, some years before, by a swelling at the root of the wisdom- 
tooth of the right side, and the inconvenience caused by its pressure had 
become so great as to lead her to take measures for its removal. 

"Upon consultation, it was decided that a portion of the jaw would proba- 
bly require removal, the tumor having been first exposed by an incision made 
inside of the mouth, to verify its character. 

" The following operation was performed under the influence of ether: An 
incision was made in the most prominent part of the tumor in the mouth, 
upon which a large quantity of glairy fluid escaped. Upon passing the finger 
into the opening, it was found that the whole jaw, at this point, with the 
articulating and coronoid processes, was expanded into a mere shell, at some 
parts as thin as parchment, and destitute of osseous substance. It was with- 
out solid contents. Under these circumstances, and considering the good 
health and youth of the patient, it was determined to make the attempt to 
save the jaw. A portion was therefore removed from the sac, and with the 
fingers the sides of the cavity were made to collapse, so as to come in contact 
with each other. In order to excite still further irritation, a bit of cotton 
cloth was forced into the interior, and the end left projecting into the mouth. 
A moderate degree of irritation followed, and in a day or two the pledget was 
removed, suppuration having commenced in the sac. The aperture was 
dilated from time to time by the introduction either of the finger or of a 
bougie, and the sac injected with tincture of iodine. In two or three weeks 
she left the hospital, with the tumor reduced to about half its original size. 
From that time until the present, she has occasionally visited me at my house, 
and by keeping the external opening free, and occasionally irritating the 
interior of the sac, a solid mass of bone has been deposited anew, and the 
jaw has resumed somewhat of its original shape. The sac is in the way of 
becoming entirely obliterated. 

" In November, 1863, 1 again saw the patient, who came to consult me, not 
about herself, but about a friend. All signs of the tumor were gone, and the 
jaw had regained almost its natural shape; but a small aperture still existed 
at the site of the former opening into the mouth, from which a glairy fluid 
was occasionally discharged. She was quite well, and all the functions of the 
jaw were perfectly performed. 

" Subsequently she applied to me with a similar tumor, but of a much 
smaller size, which had appeared anterior to the site of the first one. It was 
treated in a similar manner, with similar result. 

"Case II.— May 23, 1863, Dr. Bennett, of Uxbridge, Mass., brought me 
as a patient a gentleman fifty-six years of age, with a large tumor on the 
right side of the face and parotid region. He was of a pale and yellowish color, 
much emaciated, and his aspect at first struck me as that of a person sutfering 
from malignant disease. He said that, five years before, while eating, he 



854 ORAL DISEASES AND SURGERY. 

from their position and size, being seldom larger than an ordinary 
pea, and mostly situated in some part of the palatiDe processes of 

had the sensation of something giving way in the neighborhood of the ascend- 
ing ramus of the lower jaw. Shortly after, a tumor appeared in that region, 
which had slowly increased to its present size. Before making an examina- 
tion, it was not easy to say whether the tumor was connected with the parotid 
gland or with the jaw. Prom the first commencement of the tumor to the 
present time, mastication and, for a good part of the time, deglutition had 
been much interfered with. The tumor had been examined by many physi- 
cians of experience, and by most of them considered as a parotid tumor, and, 
as the patient inferred, although he was not directly told so, of a malignant 
character. It extended backward into the parotid region, upward upon the 
face, and inward so as to occupy the right half of the palate, and was covered 
with a highly irritable mucous membrane, somewhat cedematous, and similar 
to what we often see investing malignant tumors in the mouth which have 
made their way through from the neck. During an examination, the patient 
said there had been of late a slight discharge of fluid into the mouth, and on 
making a careful inspection a minute aperture was detected at the point 
where the last molar tooth had been removed. 

" On introducing a probe at this point, a jet of serum, mixed with flakes of 
lymph, was projected to a considerable distance. I immediately enlarged the 
opening with a knife, so that I could introduce the finger. This was a matter 
of some difficulty, however, as the patient's jaws had been for a long time 
nearly closed in consequence of the disease. The finger penetrated into a 
large sac extending far out of reach, and, on investigation, it soon became 
evident that the whole tumor was formed by the expansion of the jaw from 
the development within it of an immense cyst. On withdrawing the finger, 
a barrier of bone was felt extending across the jaw, and behind it, under the 
first molar tooth, another smaller sac was discovered. 

" I now decided to treat this case in a similar manner to the preceding one. 
An oblong piece of about an inch in length and half an inch in width was 
removed by scissors from the wall of the cyst, and, with a finger of one hand 
in the mouth, and a finger of the other on the outside of the face, the sides 
of the cyst were broken down, giving way under pressure like parchment, 
with a crepitating noise. The projection of the tumor on the face, as well as 
within the mouth, became in a great measure effaced. There was a slight 
but unimportant effusion of blood. The patient returned home under the 
charge of his physician, with the intention of pursuing pretty much the same 
course as was adopted in the former instance. On account of his age, and 
the debility caused by the want of proper nourishment, and owing to the 
difficulty of mastication, he was ordered tonics and a nutritious diet. 

"About four weeks later I saw him again. Everything had gone on well. 
The tumor was not more than a fourth as large as formerly, and bone had 
begun to be deposited in the walls of the sac. His health was wonderfully 
improved, and his complexion had assumed a healthy hue. 

"December 8, 1863. — I saw him for the third time, so altered for the 



TUMORS OF THE MOUTH. 855 

the superior maxillae. Any obscurity, however, in these tumors is 
readily dispersed by thrusting into them a bistoury, or, as suggested, 

better as scarcely to be recognized as the same person. The jaw externally 
had resumed its natural shape, and, on examination with the finger, its dis- 
tinctive anatomical marks and processes could be felt. On the inside, where 
the incision had been made, a deep sulcus was observed, lined with mucous 
membrane, into which a probe could be passed into the ascending ramus. 
There was no discharge to be detected, and the power of mastication was as 
good as ever. The only trouble he experienced was from the lodgment of 
food in its cavity. 

"Three months later, he was seen with the jaw in a perfectly healthy con- 
dition, having all its functions, and the only change from the normal state was 
perhaps a somewhat more solid and thickened condition than natural, with a 
sulcus existing at the back part where the tumor had originated. 

" In 1866 he made me a visit for the purpose of showing the complete suc- 
cess of the operation. 

" Cystic Tumor of the Upper Jaw. Case III. — A young lady, aged sixteen, 
of English parentage, was brought to me in May, 1865, on account of a tumor 
which had been developing for the last three years, in the alveolus of the 
right upper jaw, just above the canine and bicuspid teeth. Three years before 
the nerve of the canine tooth had been destroyed by arsenic, and the carious 
cavity filled with gold, the first bicuspid also being filled at the same time. 
Irritation soon commenced at the roots of these teeth, and gradually, almost 
imperceptibly, a swelling appeared there. A month before she came to me, 
this tumor opened at its most dependent part, discharging a glairy fluid, which 
continued to exude until I saw the case. 

" The aperture admitted a small probe, which penetrated into a deep, smooth 
cavity. With the finger, the tumor from below appeared firm ; but, when 
pressed upon under the gum, a degree of elasticity was distinguished. 

" I informed the parents of the young lady that the disease was a cystic 
tumor of the bone, and advised an operation. This was assented to. The 
patient was etherized, and a cut made into the tumor. The mucous membrane 
was then dissected up from its surface, so as to expose so much of the bony 
sac as would admit of a free opening being made into it, and the portion of 
bone" was removed with scissors. The finger could now be passed freely into 
the cavity, which was quite smooth and entirely lined with membrane ; it 
was not penetrated by the roots of any of the adjacent teeth. The cavity was 
stuffed with lint, in order to excite inflammatory action, for the purpose of 
obliterating the sac. 

" The operation had all the effect that could have been desired. In the 
course of a couple of months, granulations filled up the cavity, entirely oblit- 
erating it. She was completely relieved of the disease. 

" One or two other cases of cysts in the upper jaw I have treated in the same 
way, with a similar result." — J. Mason Warren, M.M.,/ro?n a paper read 
before the Massachusetts Medical Society. 



■■ 



856 



ORAL DISEASES AND SURGERY. 



the exploring-needle. The dental surgeon particularly would remark 
from the sense of touch whether or not the contents are tooth-sub- 
stance. 

Fig. 266 is a cut furnished the author by Dr. Goodwillie, representing a 
dentigerous tumor, treated by section. Examination revealed the following : 

Fig. 266. — Dentigerous Tumor. 




On the top of the tumor, as is seen, was a portion of the enamel of the 
crown of a tooth, very much like a half-decayed deciduous molar. The part 
below this, in external appearance, was rough on the surface, and seemed 
dense in structure, with the exception of a concave surface on the bottom of 
the tumor, which was quite porous, and sticking out from this were a number 
of spines, between which were minute openings into the centre of the tumor for 
the passage of the vessels of the pulp. 

Alongside of this were two other concave surfaces, not so deep, but dense and 
somewhat smooth. These were produced by the cusps of a molar tooth found 
below the tumor at this point, but very much destroyed by the pus in which 
they were found. These were probably the cusps of the first permanent molar, 
and the tumor was the last deciduous molar presenting this abnormal appear- 
ance. No other teeth were found. 

On making a section of the tumor, there were seen columns or spiculse run- 
ning from the circumference to the centre, forming quite a net-work, in which 
the pulp was held, so that, instead of there being one pulp chamber, there 
were many. 



TU310BS OF THE MOUTH. 



857 



Osteo-dental tumors not unfrequently have as their contents un- 
developed teeth. Only a few days ago the author saw a couple of 
bicuspid crowns, evidently long dead, which had been removed from 
one of these oral compound cysts. 

Such osteo-dental tumors, then, as just illustrated, may be viewed 
as the most simple of these compound cysts. Another class, the com- 
plex osteo-dental cyst, may now claim attention. No better illustra- 
tion of this class of tumor can be found on record, perhaps, than in 
the memoir of the Guadeloupe banker's son, by M. Forget, presented 
to the French Academy, and so ably and happily republished in 

Fig. 267, drawn from a section of this tumor, made by Dr. Arnold, repre- 
sents the dental tissues in a deranged and distorted condition. The internal 
structure was very much fenestrated. 

Fig. 267. 

b 




a, a, represents the enamel at the top of the tumor penetrating into fissures 
or depressions in the mass below. 

b, b. Here is represented the dentine, passing from the centre in two direc- 
tions, — in one instance passing between two layers of enamel, and in the 
other between enamel and cement. 

c, The cement is here to be seen recognized by the presence of lacunae. 
/»/>/» represent the fenestra?, once occupied by the dental pulp. Around 

some of these may be seen the distorted dental tubuli. 



858 ORAL DISEASES AND SURGEBY. 

English some years since by the publishers of the Dental Cosmos. 
As the illustrations and text are still in possession of that journal, 
the reader interested in the subject cannot do better than give them 
most attentive consideration, while certainly the author cannot do 
better than use them. I preface by remarking that by a complex 
osteo-dental tumor is meant a cyst containing some complex mass, 
which common observation, or the microscope, reveals as being 
made up of irregular developments of dental tissues.* 

* Observation. — 1. Osteo-Dental Tumor, size of a large Egg, encysted in 
the thick part of the Inferior Maxillary — Ulcerous Inflammation of the Parietes 
of the Cyst — Numerous Ossifluent Fistulas — Resection of the left half of the 
Body of the Jaw and a portion of its Branch — Cured. 

Early in May a banker, of Guadeloupe, introduced to M. Forget his son, 
whom he had brought to Paris with the intention of subjecting him to the 
necessary surgical operation for the remedy of a disease of the inferior maxilla, 
which had made its first appearance when the patient was five years old. 

History or the Disease. — At that period (five years), young L. suffered 
from pains in his left jaw ; they were for some time intermittent, then con- 
tinuous and acute. "When the patient was seven years of age, two small 
healthy molars were extracted, under the impression that they were prevent- 
ing the evolution of the second teeth. The operation gave great relief, and 
the pain ceased; but shortly afterward a small, round, hard tumor appeared 
on the external face of the jaw, near the alveoli of the teeth that had been 
removed. The tumor caused no suffering to the patient, and made no sensible 
progress for a period of eight years. The whole of the left side of the jaw 
then became tumefied, and the bone, in the language of the patient, broadened 
and rounded. He also observed, at this time, that the large molars, which 
were regularly developed on the right side, were wanting in the diseased 
part. 

This morbid enlargement was accompanied by frequent fluxions of the 
gums, cheek, and whole left side of the face. The recurrence of this fluxion 
was attended with great pain, and caused an increased tumefaction in the soft 
parts to such an extent that the difference between the sides of the face became 
absolute deformity. 

In November, 1854, a violent inflammation occurred in the base of the jaw 
and the cervico-maxillary region. Antiphlogistic treatment was employed, 
two applications of leeches were made, and the inflammatory symptoms de- 
creased, and, fifteen days afterward, purulent matter formed in the thick part 
of the cheek, which opened spontaneously, allowing the issue of a large quan- 
tity of fetid pus. The opening of the abscess became fistulous, the surrounding 
tissue then detached, and, under them, the bone was naked for a very con- 
siderable extent. 

Present Condition. — Young L., aged twenty, is strong, well developed, 
with an excellent constitution, and health perfect in all respects, excepting 
the local affection. 

The disease appears externally in a considerable tumefaction of the left 



TUMORS OF THE MOUTH. 



859 



With the cases presented in the text and foot-notes we have studied 
the extremes : a simple cyst, with a tooth in it, and a tumor so com- 



Fig. 268. 



cheek, which is more than three times its natural size, and the tumor has- 
caused a very marked eccentric development of the corresponding maxillary 
bone. 

"When the patient opens his mouth, which he does without effort, the whole 
left side of the bone is seen to resemble a large turkey-egg, — the base of the 
jaw being confounded, without appreciable line of demarkation, with the 
internal and external faces, which describe a very considerable curve. 

The tumor is uniform, without depressions or any irregular swellings upon 
the surface. It does not yield to pressure, and no part of it gives that sound 
of crepitation which is characteristic of attenuation of the osseous tissues. 
The external swelling hides the superior and lateral part of the neck ; the 
enlargement of the bone has forced the tongue from its true direction, and 
the floor of the mouth has been driven from the left to the right. 

The alveolar ridge, singularly enlarged, contains none of the grinding 
teeth, except the first bicuspid, which stands regularly in its socket. The 
tissue of the gums is dark-red, and unusually thick and hard. In a circum- 
scribed spot, about the size of a twenty- 
centime piece, the tissue is broken, and 
exhibits an unequal, wrinkled, grayish 
surface, which gives a dry sound when 
struck with a metal, as if the crown of 
a tooth were hidden in the cavity. 

In order to complete the symptomatic 
description, it is added that there are 
many ossifluent fistulous openings at 
the base of the tumor, and much hyper- 
trophy and hardening of the submaxil- 
lary lymphatic ganglion. 

The functional disorders arising from 
the pathological condition, at first very 
slight, are noticed at this stage as in- 
creasing everyday: embarrassment of 
vocal utterance, mastication painful 
and incomplete, deglutition effected 
with difficulty, and respiration very 
difficult every time inflammation is re- 
newed in the tumor ; lastly, the patient 
suffering from two serious inconven- 
iences, — one, the very marked deform- 
ity of the face ; the other, the incessant 
flow of fetid pus, proceeding from the 
complicated fistulae of the osteo-dental 
caries. 

M. Forget here describes the operation, the usual resection. 




One incident. 



860 



ORAL DISEASES AND SURGERY. 



plex in character and structure that no one but the rnicroscopist 
might hope to be able to recognize it. Yet these tumors, differing 

however, should be remarked : in making his anterior cut with the chain 
saw, he alludes to coming in contact with a tooth placed horizontally in the 
thick part of the bone, precisely under the alveolus through which he was 
cutting. 

Anatomical Examination of Tumor. — With the surrounding soft parts, 
it is described as being an exact ovoid. The soft parts, adhering to its ex- 
ternal face, were found marked with many fistular passages, ending at inflamed 
and ulcerous points of osseous tissue. This tissue was thin, soft, and depress- 
ible, and perforated by two orifices leading into the interior of the cyst, 
from which exuded a purulent, viscid, reddish liquid. A stylet introduced 
into one of these passages was stopped by a hard body, which, under percus- 
sion, sounded like a compact tissue deprived of its periosteum. This ob- 
ject was reached by dissecting off the gums, which, condensed into a thick 
bed, formed a sort of operculum for the upper part, completing the cyst in 
which the morbid product was situated. The dissection exhibited that the jaw 
from the ramus to the premolar had been changed into a cavity containing 
a compact, saxiform, ovoid mass, the size of a large egg^ grayish, unequal 
surface, studded with small tubercles, surrounded by a bed of enamel, and 
completely buried in the thick part of the bone. (See Fig. 268.) 

Fig. 269. 




Next, the tumor was divided along its axis into two unequal parts, each 
confined to the corresponding half of the osseous cyst that was comprised in 
the division. This revealed the composition of the tumor : it was formed of 
a smooth, glossy, compact, homogeneous, ivory-like tissue, of a whitish-brown 
color. In the centre of it a kind of regular disposition of its elements is 
described as existing, discernible by the naked eye. (See Figs. 269 and 270.) 



TUMORS OF THE MOUTH. 



861 



so widely in their features, are alike in the most important one of 
being benign. Their prophylaxis is the same, and for a good dis- 
tance their surgery runs side by side. 

Between the tumor and the wall of the cyst was a thick, fibro-cellular tis- 
sue, free on the side of the former, where it covered the whole intramaxillary 
portion, and was joined to the latter by filamental prolongations of a cellulo- 
vascular appearance, — these being attached to the numerous openings that 
covered the face of the cyst. The external surface of this membrane was 
bathed with a muco-purulent liquid, smelling like dental caries. 

Fig. 270. 




At the base and anterior extremity of the tumor, an indentation is described 
fitting the crown of a large molar that stood between it and the maxillary 
bone. (See Fig. 270, b.) A portion of the same tooth caused a slight eleva- 
tion on the external face of the jaw. (Fig. 269, c.) M. Forget also describes 
the tooth encountered in the operation. (Fig. 269, d.) Its location, as will be 
seen, is directly beneath the alveolus of the first molar, which is standing in 
its true position. (Fig. 269, e.) 

All the teeth, with the exception of the last two molars, it will thus be seen, 
were found, and the space appropriated for them was filled by the tumor. 
"What, then, queried M. Forget, could have become of these two great molars ? 
It could not be, he argued, that the bulbs, compressed from their very origin, 
had disappeared without leaving a single vestige of their existence. The 
numerous instances, he held, that had occurred of the simultaneous develop- 
ment of teeth and anomalous productions in the very centre of the maxillary 
would not allow him to think of accepting such an explanation. In all the 
analogous cases that had fallen under his observation, the teeth were of- the 



862 



ORAL DISEASES AND SURGERY. 



Dental tumors, intermediate to these two classes, are of various 
features. But, with an ability to recognize the dental elements, — 

ordinary dimensions, and complete in number, although removed from their 
normal position, and sometimes buried even in the morbid substance itself. 

Let us now, that we may fully comprehend such a class of cases, pursue 
the study of this particular one. 

Fig. 268 represents the left half of the body of the inferior maxillary bone. 
hollowed into a large cavity, containing an ivory-like bony tumor. 

d. Side view of the alveolar edge. 

a. Orifice of the dental canal upon the surface of the resection of the bone 
in the continuity of the ramus. 

b. Plane of the cut in front, showing the second small molar which was 
found in it. 

c. Crown of the first molar, in regular position. 

Fig. 271. 
± 




a % 

Figs. 269 and 270. The two halves of the anatomic section, divided accord- 
ing to its axis (osseous cyst, and included tumor). 

Fig. 269. — c. Crown of great molar, seen through a notch in the outer wall 

of the cyst. 

d. Second small molar. 

e. First small molar. 



TUMORS OF THE MOUTH. 863 

with an understanding of the minute histology of enamel, dentine, 
cementum, and pulp-substance, — what difference can it make, having 
eyes and a microscope, how these elements aggregate ? 

a and b. Points of the same wall, perforated by the prolongation of the 
tumor. 

/. Summit of the most elevated of these. 

Fig. 270. — a. Interior aspect of the tumor. 

b. Great molar inverted. 

c and d. Cellulo-fibrous membrane, interposed between the osseous cyst and 
tumor. 

Fig. 271. Microscopical examination. 

M. Forget, in presenting this case to the French Academy, remarked that 
it was a duality of anatomical and pathological lesion, so rare that, after the 
strictest research, he was led to believe it unexampled in the human species. 
Thus, then, we have here, side by side, each extreme ; and, understanding each, 
there is not likely to come anything between that we may not be able readily 
to explain. 

A dental germ assuming or compelled to an abnormal position may have 
various sequelse. It may make a mal-eruption ; it may remain encysted ; it 
may die after partial development, or it may heterogeneously develop. 

"We have, then, but to consider heterogeneous development, and we have 
mastered the pathology of the lesion and all its various phases. 

First, let us dissect a tooth, — for the parts of a tooth are the parts of such 
tumors. A tooth is made up of enamel, dentine, cementum, pulp-substance, 
and periodonteum. 

Enamel of the Teeth. — Cortex strata, adamantina dentium ; crusta den- 
tium adamantina; substantia vitrea. 

The enamel of a tooth is that portion which caps the crown. In structure 
it is fibrous ; its fibres radiating from the centre to the surface. 

In microscopic structures, the enamel (Owen) consists of long and slender, 
solid, prismatic, for the most part hexagonal, fibres of phosphate, carbonate, 
and fluate of lime ; which are essentially the contents of extremely delicate 
membranous tubes. 

Dentine. — Os dentis, substantia ossea ebur dentis. This is the portion of 
the tooth between the cementum and enamel and between the pulp and the 
enamel. It makes up the great body of the organ. Dentine is composed of 
numberless tubules, these being not larger than the one-ten-thousandth of an 
inch in diameter ; their course is waving, each tubule having several curves 
resembling, according to Ketzius, the Greek letter -&. " Professor Eetzius 
confirms the observation of Miiller, that the tubes contain an organic earthy 
matter in granular masses, which disappear under the action of dilute muri- 
atic acid. The cells, and the small tubes which radiate from them, also con- 
tain earthy matter, as in bone. They are naturally white and opaque, but, 
after maceration in dilute muriatic acid, become colorless and transparent.'' 

Chemically, dentine differs from enamel principally in the absence of the 
fluate of lime. 



86 ± ORAL DISEASES AND SURGERY. 

The author once saw a tumor taken from a maxilla, which 
looked like a mass of ivory; it was quite as large as two of the 

Cementttm — Crusta Petrosa. — The ceruentum of a tooth is that portion 
which invests the fangs. In character, it corresponds quite closely to the 
osseous structures. The microscope demonstrates clearly the existence of 
Haversian canals, and the so-called corpuscles of Purkinje, or. as Eobin 
prefers to term them, osteoplasts. 

" In growing teeth, with fangs not fully formed, the cement is so thin that 
the Purkinjean cells are not visible ; it looks like a fine membrane, and has 
been described as the periosteum of the fangs, but it increases in thickness 
with the age of the tooth, and is the seat and origin of what are called exos- 
toses of the fangs, which are wholly composed of it." " It is the presence of 
this osseous substance/-' says Professor Owen, '-'which renders possible many 
well-known experiments of which the human teeth have been the subject r 
such as their transplantation and adhesion into the combs of cocks, and the 
establishment of a vascular connection between the tooth and the comb,'' etc. 
Under every modification, the cement is the most highly organized and most 
vascular of the dental tissues, and its chief use is to form the band of vital 
union between the denser constituents of the tooth, and the bone in which the 
tooth is implanted. 

Dextal Pulp. — The pulp is that vascular, reddish-gray, highly-sensitive 
substance occupying the cavity of the tooth. It is made up of delicate con- 
nective tissue, in which ramify the dental nerve, artery, and vein. 

" When," says Mr. !N"asmyth, " the internal structures of a dental pulp are 
examined, the number of minute cells which present themselves in a vascular 
form is remarkable ; they seem, indeed, to constitute the principal portion of 
its bulk." Mr. N. describes them as " varying in size, from the smallest 
microscopic appearance to one-eighth of an inch in diameter ; and as being 
disposed in different layers throughout the body of the pulp." This tissue is 
highly endowed, and, perhaps, more liable than any other portion of the body 
to take on morbid action : fungoid degeneration is, perhaps, its second most 
common disease. 

Periodonteal Membrane. — This is the periosteum of the tooth. Anatom- 
ically and physiologically it differs little from this general class of membranes. 
Pathologically, it may be remarked as being more susceptible to disease, and 
more disposed to assume quickly the acute conditions. For example, inflam- 
mation of the periodonteal membrane is easily provoked, and, once inflamed, 
it is ever after surprisingly prone to reassume morbid action. Again, we 
need only call to mind its epulic outgrowths, and the frequency and varied 
character of these growths. 

Familiar with tooth structure, we turn to Fig. 271, and trace a perversion 
of development in all these structures, — see them forming a tumor, strictly 
dental, yet to the last degree anomalous and abnormal. 

We return now to the microscopic examination of tumor, made by Prof. 
Ch. Kobin, Fig. 271 (400 diameters). This figure represents a portion of a 
slight cut made into the tumor represented in Fig. 270, a. 

The preparation is taken from near the free edge, or the irregularly mam- 



TUMOBS OF THE MOUTH. 865 

molar teeth put together. He need scarcely say that it was two of 
the molars ; their germs had in some way affiliated, and, remaining 

raillated surface of the tumor. The latter is formed principally of the ivory 
or dentine, easily recognized upon the thin section by its very fine tubes, 
disposed in parallels, or nearly so, through part of their extent (Fig. 271, e). 

These tubes, radiating more or less regularly from the little depressions or 
cavities observable in the mass of the tumor (Fig. 270, a), very near to each 
other through part of their extent, become more rare, fine, and ramified 
as they approach the surfaces of the dental tumor (Fig. 271, d,f), and end 
in a very sharp point toward the lines of junction between the ivory and the 
enamel (a, 5, c), and the cement (/, g, h). The presence of the ivory, which 
forms the greater part of the tumor, demonstrates its dental nature very 
clearly. 

Enamel. — Another important particular is the presence of the enamel on 
the surface of the tumor, where it in some measure covers the irregularities 
with a varnish which moulds itself upon them in order to penetrate more or 
less deeply into the fissures or depressions that divide the tumor superficially 
into lobes. 

This bed of enamel varies in thickness from microscopic dimensions to a 
millimetre (.03937 inch), or near it, and is as irregular in places on the lower 
or adhering face as it is on the free surface, which the microscope alone 
allows to be seen. The portion of the section of the tumor that is here de- 
lineated (Fig. 271) is taken at the level of one of the points where the enamel 
(a, b) in a manner penetrates (c) into the body of the ivory mass of which 
the tumor is principally formed. 

The enamel is easily recognized by its narrow prisms, from six- to eight- 
thousandths of a millimetre in width, which are in immediate juxtaposition 
(Fig. 271, a, b). The figure shows them inclined, as by the accidents of the 
cuts in making the section. When the cut is perpendicular, or nearly so, to 
their greatest axis, their prismatic form, with five or six faces, is easily seen ; 
this is shown in the neighborhood of b, Fig. 271. 

Cement. — In the depth of the fissures, and here and there in the mass of 
the tumor, near its surface, and especially that part of the surface hidden in 
the adventitious cavity of the maxillary bone, the microscope discovers some 
trails or beds of variable thinness, formed entirely of the substance of the 
cement (Fig. 271, g). 

The cement is inclosed between masses of ivory, and is consolidated by the 
immediate contact (Fig. 271) with the masses between which it lies. It extends 
itself in places with the surface of the tumor to the neighborhood of, and even 
to contact with, the enamel. The section represented in the plate is taken at 
a point that shows this arrangement (Fig. 271,/, g, h). There are, besides, 
thin pieces of cement extending far forward into the body of the tumor. 

The cement is known to be no other than the osseous substance. The figure 
before us exhibits the characteristic elements belonging to it. These are the 
microscopic cavities, called osteoplasts, or, incorrectly, osseous corpuscles, for 
they are excavations. The air that fills the dry bone makes these cavities 

54 



866 ORAL DISEASES AND SURGERY. 

encysted, bad produced this abortion. The microscope revealed 
very distinctly the dental character of the mass, pronouncing it 
quite as distinctly as though the shapeless lump had been moulded 
to the tooth-form. 

The author has had shown him, as great curiosities, teeth with 
ivory masses projecting at right angles from their crowns. He never, 
however, has seen this anomaly where it was not plainly evident 

appear black under the microscope (Fig. 271, g) ; but in the fresh state they 
are full of liquid, and are pale and more difficult to observe than in the dry 
pieces. 

These cavities, which are in breadth and length from one- to three-hun- 
dredths of a millimetre, are always of very irregular shape, on account of the 
presence of the fine tubes that start from all their peripheries and traverse 
even the substance interposed between the osteoplasts. 

The best-joined pieces show that these little canals are subdivided two or 
three times, and are then inosculated with those of neighboring osteoplasts. 
The portion of cement shown in the plate does not exhibit this arrangement, 
which was visible, nevertheless, in the parts close to it. 

The cuts in the tumor exhibit, moreover, little openings, that are either full 
of a grayish or brown pus, or empty. These small orifices are from two- to 
six-tenths millimetre and upwards in width, and from about one to two mil- 
limetres apart. The microscope shows that these orifices accompany the nar- 
row, irregular cavities, sometimes in the form of elongated conduits, hollowed 
out of the ivory through which they pass. The instrument also shows that 
the tubes of the latter start from these cavities to radiate toward the surface 
of the tumor, in the same manner as the tubes of the ivory in the normal 
tooth start from the natural cavity of the dental pulp. These narrow, irreg- 
ular cavities, more or less elongated, traverse the mass of the tumor, and 
some of them even reach within a few millimetres of the surface. 

These cavities are, in reality, nothing more than the pulp-caVities of this 
morbid product, either rugous from desiccation, or still containing some rem- 
nant of the dried pulp in the form of a brownish or grayish powder. 

Eecapitulation. — The result of all these observations of the case is thus 
epitomized by M. Forget : 

1st. An original union of the follicles of the last two molars, followed by 
an intimate union of them, caused by phlegmasial or other action. 

2d. Under the same morbid influence, the excess of vitality in the organic 
elements of the follicles has produced hypersecretion of an ivory-like osseous 
substance. 

3d. That the irregular aggregation and diffusion of these constitutes the 
pathological growth. 

4th and lastly. Its growth has formed in the cyst, and it has maintained 
therein a permanent inflammation which has disorganized the osseous tissue 
and altered the structure of the adjacent soft parts to such an extent that a 
radical operation was necessary. 



TUMORS OF THE MOUTH. 867 

that the projection was a twin tooth, — the result of germ-union ; 
there would be a tooth missing in the arch. 

Many curious illustrative instances could be mentioned of anoma- 
lous incongruities in dental evolution ; but, as we are prepared to 
understand, we would find them in character the same, — enamel, 
dentine, cementum, and pulp structure. The arrangement only 
would be- found to differ; with our eyes, or assisted by the micro- 
scope, we should be able to pronounce concerning any of them, This 
is dental. 

The ability, then, to distinguish a dental from a malignant osteoid 
tumor must certainly prove a source of much satisfaction ; for, as M. 
Forget remarks, if intervention cannot be too radical in an in- 
stance of cancer, it is certain, on the contrary, that more caution 
and moderation are necessary when it is a question of a lesion 
which is essentially local and of a benignant nature, and allows the 
surgical operation to be restricted to the precise limits of the lesion, 
without its being necessary to provide against an improbable repe- 
tition by encroaching upon the osseous tissues that border on it, 
and thus subjecting the patient to a mutilation which could not be 
justified. 

Data. — 1. There are twenty teeth in the deciduous denture, which 
twenty are to be replaced by thirty-two, each of which is to be at 
least twice the size of its predecessor. 

2. A contracted maxilla, having no accommodation for certain 
teeth, the germs of which are in the jaw, gives us, among other 
lesions, irregularity in dental evolution. 

3. Irregularity in evolution yields morbid conditions, as de- 
scribed, which conditions are influenced, not unlikely, by peculiari- 
ties of the general organization and manner of interference with 
development. 

4. An overcrowded arch will surely yield periodonteal and other 
minor troubles, and may produce lesions of grave character. The 
extraction of certain of the bicuspidate teeth of the permanent set 
should therefore be practiced, whenever time shall make evident the 
existence of contraction on the part of the arch. 

5. Dental tumors vary from simple cystic growth to such per- 
verse and anomalous evolutions that the microscope alone is capable 
of explaining them. 

6. A dental tumor is an abnormal growth, having its point of 
departure and development in irregularity of dental evolution. 

t. Dental tumors are benign ; operations for their cure promise 



868 ORAL DISEASES AND SUBGERY. 

all success, and may be practiced in exclusive consideration of the 
disease as it locally exists. 

8. The existence of a dental tumor is to be inferred, cseteris pari- 
bus, in case of deficiency and derangement in the dental arch. 

The existence of very large cysts, as occasionally found in the 
lower jaw, involves in a treatment the preservation of the contour 
of the parts, — complete section of the bone being never, as a pri- 
mary operation, permissible, Such required precaution is best 
secured through the preparation of a plate fitting the teeth, pre- 
cisely as directed for fractures when the inter-dental splint is used. 
(See Fractures.) This plate, before the cyst is at all interfered 
with, is to be placed in position, and the jaw fixed in its place. This 
accomplished, — although it adds to the inconvenience of the treat- 
ment, — a cyst may be crucially incised and stuffed with very little 
danger of fracturing the continuity of the parts. Cysts of such 
delicate attenuation are, however, not at all common, a consoli- 
dating and supporting periosteal exudate counterbalancing to a 
marked extent the attenuation. The author, at the present time, 
has under treatment a cyst of the lower jaw quite the size of an 
ordinary orange, yet the bone seems as solid as iron. The patient 
in this instance, however, is a remarkably vigorous laboring man. 

Cysts may have a self-explaining origin, yet, from the presence 
of a systemic vice, depart from their homologousness. As hetero- 
clitic contents are met with, so will be found want of success in 
attempts at cure by the granulative process. The septi alluded to 
as seen so frequently in the simple cyst will be found at times 
replaced by what is known as the soft multilocular cyst. Again, 
the cavity will be found filled with a pulpy, liver-colored, turgid 
mass. It has been the experience of the author that exactly in the 
degree in which these cysts depart from simplicity, do they afford 
evidence of the change by the sympathy expressed in the overlying 
mucous membrane. (See Cysto- Sarcoma.) 

In accounting for the formation of the ordinary dentigerous cyst, 
the hypothesis has been advanced that the condition is due to a 
morbid secretion into and enlargement of the capsule of the enamel 
organ : this, however, is certainly not the explanation, as the true 
enamel membrane. — the tunica propria — is always found in a normal 
relation and position. That an effusion might have occurred 
between the enamel and its matricial membrane — the tunica reflexa 
— is barely probable, although possible ; the enamel of the crowns of 



TUMORS OF THE MOUTH. 869 

the encysted teeth being commonly too perfect to warrant inference 
of interference of any kind in the process of development.* 

The teeth most frequently found encysted are the dentes sapi- 
entise ; this would be inferred from the relation of these organs. 
After the wisdom-teeth, the next in frequency are the cuspidati. 
According to the observations of Dr. Bolles (see his Prize Essay), 
the sexes seem nearly equally liable. Most of the instances collated 
by this author are noticed as having occurred between the ages of 
ten and forty : one to ten, one case ; ten to twenty, nine ; twenty to 
thirty, nine ; thirty to forty, three ; forty to fifty, none ; fifty to 

* " The exciting causes are often unknown, and probably various. The 
attempts of the impacted teeth to reach the surface have an exciting action 
in certain cases ; but, on the other hand, such teeth may lie quiet in the jaw 
during the entire life, and cause no trouble, or may be found inclosed in a 
C3 T st after all attempts at growth had been given up for years. That the 
disease should follow the extraction or aching of carious teeth is not remark- 
able, considering how common these are at all ages ; yet such irritation in 
some cases may have been the exciting cause as well as the obstinate resist- 
ance of a milk tooth to the advance of its follower. In the first and second 
cases given in the tables the disease was evidently excited by the blows which 
preceded. The additional presence of undeveloped teeth in the jaw is, of 
course, essential in all these cases, for without these the affection cannot exist. 

u Whatever may have been the exciting cause, the pathology is essentially 
the same. The disease is due to a morbid secretion into and enlargement of 
the capsule of the enamel organ of the unfortunate tooth. This is shown by 
the position of the latter, whose crown lies exposed in and to a certain degree 
faces the cavity. This position serves to distinguish this cyst from those 
instances where innocent teeth, before eruption, have become displaced by 
the growth of solid or even fluid tumors in which their own enamel organs 
bore no part, or other cavities which simulate it, but are as distinct from it 
as hydrocele from scrotal abscess. If the fang instead of the crown project, it 
is not a true dentigerous cyst. 

" Probably the reticular parenchyma of the enamel organ is destroyed by 
its expansion, but in the multilocular forms this may possibly aid in forming 
the partitions. The whole inclosure is lined with a serous membrane, which 
is sometimes considerably thickened and vascular, and continuous over the 
crown of the tooth, as would be expected from its origin. A microscopical 
examination of such specimens would be very interesting ; it should show an 
absence of the ' cuticula dentis' from the tooth and the continuousness of its 
covering, the enamel membrane, with the rest of the .wall. The fluid is 
usually serous, but may be purulent, — contain cholesterine, flakes of lymph, or 
shiny matter, or vary in other respects. A bony exostosis in one case accom- 
panied the cyst, and may have been the exciting cause of it. Other compli- 
cations have occurred." — Extract from a Prize Essay on the Dentigerous Cysts, 
by W. S. Bolles, M.D. 



870 ORAL DISEASES AND SURGERY. 

seventy, three ; — the duration being between four months and 
thirty years ; the lists of ages being at time of operations. 

Dentigerous cysts, as would be inferred, are related with the 
permanent (or, as they would in this connection be better named, the 
successional) teeth. One or two exceptions, however, are related: 
one from the practice of Mr. Alexander Edwards, of Edinburgh, being 
in the person of a young man "in whose upper jaw, just below the 
orbit, a tumor had developed. This tumor consisted of exostosis 
from the maxilla, combined with a bony cyst, containing a tooth 
which was pronounced by Prof. Goodsir to be a temporary molar.'* 

Of the various preparations in existence of cysts of the jaws, the 
largest with which the author is familiar is one in the Museum 
of St. George's Hospital. This immense tumor rested upon the 
clavicle when the head of the patient was thrown as far back as 
possible. This tumor may be found figured in Holmes's System of 
Surgery, vol. iv. p. 459. 

Cystiform Antra. — Fig. 272 represents a cystic tumor, or, rather, 
expansion of the walls of the antrum, as occasionally met with. The 
cyst represented in the view occurred in the person of a young 
gentleman some twenty years of age, from whose jaw it was re- 

Y 1G 272 Antral move d two years back. This cyst, the size of an 

Cyst. ordinary orange, was successfully treated with- 

out external incision, the soft parts being dis- 
sected off by pulling outward and upward the 
angle of the mouth ; the wall of the cyst, about 
the thickness of ordinary parchment, was cut 
away with a chisel. This particular cyst was 
without contents of any kind. After the removal 
of the vault, the soft parts were permitted to 
fall into the cavity of the sinus : no deformity 
resulted, and no trouble has since been experi- 
enced. 

An interesting feature in this character of cases 
is found in the tenacity on the part of the antrum, after operation, 
to maintain its cavity. The author has tried his best to obliterate 
this sinus by compelling granular activity in its mucous membrane, 
but so long as he has been enabled to watch cases (and in one 
seven months elapsed before the overlying tissues so covered in the 
part as to conceal it from observation), in none of them was he able 
to satisfy himself as to what was the subsequent condition of the 




TUMORS OF THE MOUTH. 871 

sinus. His impression is, however, that the mucous membrane 
maintains itself, and that a species of cavity continues to exist. 

Hydrops antri is another form of cystiform enlargement of this 
cavity. The dilatation in these cases is gradual and painless, and 
when the bone becomes expanded to any considerable extent, 
fluctuation is commonly apparent, the vault of the cyst yielding 
readily to pressure. If any obscurity exists, it may be removed by 
the use of the exploring-needle. It sometimes happens in these 
cases that the floor of the orbit becomes the yielding point, or it 
may be the canine fossa, the tuberosity, or the hard palate ; the 
latter boundary, however, according to common observation, is the 
most frequent seat of the enlargement, forming the tumor within 
the mouth. 

Hydrops antri depends, in many cases, on the formation of a 
cyst within the cavity. In others it may be viewed as a simple 
mucous engorgement, the natural outlet into the meatus being, 
from some cause or other, obliterated. A very expressive illus- 
tration of the first of these conditions was exhibited in a specimen 
taken some three years back from the antrum of a young man. In 
this case the cyst seemed to spring from the root of the second 
molar tooth, or its immediate neighborhood ; the mucous membrane 
had been dissected up, and covered the cyst as a reflex tunic. Al- 
though this particular tumor was not large enough to exhibit 
external evidence of its existence, yet there are no reasons for infer- 
ring that such tumefaction would not eventually have resulted. A 
case of interest in this direction is recorded in the practice of Dr. 
Chase, of Iowa City, who reports it in the Dental Cosmos, accom- 
panying the report with a diagram.* 

* Description or Case. — "An Irishwoman, aged forty years, came to have 
the right first upper molar extracted. I found her teeth in a bad condition 
generally: they were decayed and loose, and the gums congested. This par- 
ticular tooth was decayed and very loose. On pressing it, the alveolus 
seemed to move with the tooth. Adjoining it in front was the root of the 
second bicuspid, — the crown gone. 

"As she was of that class who make no attempt to preserve their teeth, I 
extracted the molar without hesitation. She had told me that her 'jaw' had 
ached for three or four months previous to this time. On applying the for- 
ceps, the beaks readily passed under the gums without lancing, and the tooth, 
much to my surprise, came away with a very slight application of force. But 
this surprise was not equal to my astonishment when I saw what I had 
brought away with the tooth,— namely, a large quantity of alveolar substance. 



872 



ORAL DISEASES AND SURGERY. 



M. Giraldes describes multiple cysts of the antrum ranging in 
size from a pea to a pigeon's egg. These cysts he illustrates as 



the bicuspid root, and a fibrous connective-tissue tumor, nearly an inch in 
diameter, attached to the tooth, and inclosing two of the roots, namely, the 
posterior buccal and the palatine root. 

Pig. 273. — Secondary Ctst or the Antrum. 




1, root of second bicuspid attached to alveolus ; 2, neck of tooth and border of alveolus 
3, walls of antrum, palatal side ; 4, centre of crown of tooth; 5, tumor; 6, tartar, cover- 
ing the cavity of decay. The buccal aspect of the tooth was similar in appearance to the 
palatal surface which is seen in the engraving. 

" After being in alcohol three days,* the tumor was nearly white, and had 
shrunken to one-third its original size. On cutting it open, it was found filled 
with a solid structure. The consistence was that of tubercle, or pressed cheese- 
curd ; the color, light yellow, tinged in most parts with red. 

"The roots within the tumor were nearly free, and covered with their 
periosteum, which had thickened into a loose, spongy mass, extending even 
to the base of the body of the tooth. The appearance was like that of roots 
involved in alveolar abscess. The walls of the tumor were not composed of 
detached dental periosteum. There were apparently two coats, the outer 
fibrous, like periosteum ; the inner a mucous one, like the lining of the nasal 
cavity." 

The pathology of the case, as inferred by Dr. Chase, is that the tooth 
decayed to the pulp-cavity, and that the pulp, after repeated inflammatory 
attacks, died. Putrefaction of that organ occurred, provoking periodontitis ; 
after awhile suppuration occurred, and the disease became chronic. The perio- 
donteum became thickened and spongy, and continued irritation caused a 
proliferation of connective-tissue corpuscles, thus eventuating, finally, in the 
formation of the cyst. 

This inference is, probably, the true explanation of the cyst. The trouble, 
however, seems to have been seated primarily upon the bicuspis and not upon 
the molar roots, — involving the latter secondarily. This tumor, although it 



* It is to be regretted that an examination was not made at once. 



TUMORS OF THE MOUTH. 873 

being found filled with a fluid sero-albuminous, thin or glairy, and 
differing in color in different cases, being brown, yellow, or blood- 
color. The suppuration of these cysts is described as the occa- 
sional cause of resisting abscess. These cysts this author believes 
to be quite common, and that they are the cause of many of the 
enlargements encountered. Their origin he locates in morbid 
changes of the mucous glands.* 

possessed not the contents of the one operated on by the author, has a similar 
pathological signification : it constitutes an instructive example. 

In cases of this kind it will be seen at a glance that, however patulous the 
natural outlet might be, the contents of the tumor could not by such means 
find egress. In the second character of cases, the contents are just within the 
cavity, but the engorgement of the tissue bounding the outlet has closed the 
foramen. A case described in the chapter on Diseases of the Antrum exhibits 
the dangerous and destructive effects of such accumulations when unappreciated 
and untreated. 

* Recherches sur les Kystes muqueux du Sinus maxillaire. 



CHAPTER XLII. 

THE TU3I0RS OP THE MOUTH. 

N X - Z X P L A I X A B L E TUMORS. 

So far we have studied tumors of the jaws, all of which, with 
the exception of certain of the epulides. we must feel are fully known 
to us through a self-explanation which we have seen to reside in 
them. From these we pass to our second classification; premising 
that, as a growing intelligence and experience may be able solidly 
to explain certain of them from the local stand-point, so it shall be 
the good office of him who explains to modify the present classifi- 
cation.* 

* " In regard to the prognosis and course of tumors, from what has been said 
you may infer : 1. That they seldom recover spontaneously, nor are they 
accessible to medicines ; and, 2. That they are partly infectious, partly not 
so. The latter point is particularly striking to unprejudiced observation. 
There are some tumors which do not return after extirpation, and others that 
not only return in the cicatrix, but come in the neighboring lymphatic glands 
and also in internal organs, as already remarked. The former have for ages 
been called benignant, the latter malignant or cancerous. This observation is 
so simple that it would seem merely necessary to study exactly the peculi- 
arities of one or other form of tumor, to arrive at ah accurate prognosis. 
But accurate clinical and anatomical study did not lead to this desired simple 
result of this dualism, but it showed that the latter did not exist, that the 
conditions were more complicated. After an exhaustive anatomical study and 
description of benignant and malignant growths, they were examined under 
the microscope and in the retort ; it was thought that the characteristic marks 
had been found now in one point now in another, and soon one discovery after 
another proved erroneous : it was thus shown that an antithesis of absolute 
malignancy and benignancy did not exist in the sense meant, and that it was 
necessary to distinguish not only solitary, multiple, and infectious tumors, 
but that a scale must also he made in the grade of infectiousness. We must 
investigate this more closely. "We call a tumor solitary when only one occurs 
in the body and causes purely local symptoms ; they are usually growths con- 
sisting of any fully-developed tissue, — fibroma, chondroma, osteoma, etc. TVe 
(874) " 



TUMORS OF THE MOUTH. 875 

The tumors now to be described are found to be so variously classi- 
fied by various authors, that any one fairly qualified may feel him- 

speak of multiple tumors when a series of similarly-organized growths occur 
only in one certain system of tissue ; for instance, when numerous chondro- 
mata occur only on bones, or numerous lipomata only in the subcutaneous 
cellular tissue, or many fibromata only in the skin, etc. As generally acknowl- 
edged, there is at the same time a predisposition, which Virchow regards as 
purely local, but which, as already stated, I must consider constitutional. In 
general, we may say that all sorts of tumors may occur as solitary or multi- 
ple, although the latter is very rare in some forms of tumors. "We apply the 
term infectious to a tumor which not only grows into th > parts around it, 
infiltrating them and thus constantly growing by apposition of new foci, but 
which may also infect the next lymphatic glands and finally other organs. 
In this respect there are very great differences : in some tumors the infection 
extends regularly only to the next lymphatic glands (carcinoma of the lips and 
face) ; in other cases from that point it extends farther, especially to internal 
organs (carcinoma of the breast) ; lastly, infection of the entire body with 
metastatic tumors, without infections of the lymphatic glands, sometimes 
occurs (some forms of sarcoma). Moreover, the rapidity with which infec- 
tion follows, varies greatly. If we examine the conditions under which 
infectious tumors develop, and their anatomical structure, we shall see that 
they occur especially in advanced age, about equally in men and women, and 
particularly often in certain organs ; that the age of childhood is disposed to 
infectious growths, especially to malignant sarcomata, while in youth and the 
first years of adult age very few tumors of any kind, and especially few malig- 
nant tumors, develop. Mode of life, good or bad food, poverty, riches, char- 
acter, nationality, and cultivation, appear to have no special influence on the 
development of tumors generally ; nor can we recognize any specific influ- 
ence of these powers on infectious tumors. The study of the anatomical 
structure of tumors has been pursued with great zeal of late, and it appears 
that a large number of malignant growths have characteristic macroscopic 
and microscopic peculiarities, but that a correct prognosis cannot always be 
based on them ; in general we may say that they are usually very vascular 
tissue-formations, disposed to ulceration, and in their course proving to 
be infectious. As it is most probable that the infection results from the 
locomotion of specific tumor-elements, some of the factors relative to reab- 
sorption may here have some effect. The quantity of blood and lymphatic 
vessels in the tumor and its immediate vicinity, the conditions influencing 
opening and closure of these passages, and the activity of the circulation 
generally, are to be considered. 

" Infectious tumors are usually at first solitary, very seldom multiple in the 
sense above indicated. Tumors that are multiple from the start are rarely infec- 
tious. When we use the terms dangerous, malignant, and infectious, as synony- 
mous, we do so without regard to the locality where the tumors are developed. 
A solitary benignant tumor in the brain is always malignant, from its locality : 
an infectious tumor at the same point possibly never goes beyond local infec- 



876 ORAL DISEASES AND SURGERY. 

self excused in marking out what to his own mind may seem a 
simplification of the subject, — simplification being the common 
object with all writers. 

In a record of 307 cases of tumors of the jaws made by Prof. 
C. Weber, the histological variety exhibited was as follows : Car- 
cinoma, 133; sarcoma, 84; osteoma, 32; cystoma, 20; fibroma, 
17 ; enchondroma, 8 ; gelatinoid polyps, 7 ; melanotic sarcoma and 
carcinoma, 5 ; angeioma, 1. 

Upon such a record it would seem that in all solidity a classifi- 
cation might be founded. This indirectly we may accept; directly, 
however, it is not a matter that concerns us. Our classification is to 
recognize but a single condition, — we here exclude, for convenience, 
any expression that might be met with of syphilis, scrofula, or tuber- 
culosis, — conditions that any surgeon would recognize, — a condition 
of many expressions, these expressions being accorded the title of 
destructive diseases by C. Weber and those who follow that mode 
of classification. Indirectly, however, we must accept a histologi- 
cal classification, as thus with most convenience we may find data 
for a study, the understanding of which is of the greatest service, 
and certainly of the greatest interest. 



tion, as it soon proves fatal. All these things are to be carefully weighed, if 
we would obtain clear ideas on these points. 

"Tumors are not always to be termed infectious (malignant, cancerous) 
because of a return at the point of operation. In this case it is very impor- 
tant to decide whether the recurring tumor has started from portions of the 
original tumor, that have been left at the time of operation (continuous 
recurrence, Thiersch), or, possibly years after a perfect operation, a new tumor 
has occurred from similar causes in the cicatrix or in its vicinity (regional 
recurrence). If the point of operation remains free, and, after the operation, 
swellings of the lymphatic glands, of the same nature as the extirpated tumor, 
appear, or if, under similar circumstances, without swelling of the lymphatic 
glands, growths occur in other organs, it may be considered certain that these 
lymphatic glands and other organs were already infected at the time of opera- 
tion, although this may not have been susceptible of proof on examination. 

" When a person is infected from a tumor, we term it a dyscrasia, just as 
we do when one is infected from a focus of inflammation. In such persons 
foreign materials circulate in the fluids of the body, inducing in them a patho- 
logical condition. In infectious tumors this dyscrasia displays itself by general 
disturbance of the nutrition, — emaciation, marasmus ; how soon and how ex, 
tensively this shall occur depends very essentially on the seat of the tumor 
and its peculiarities (softening, becoming gangrenous, ulceration, bleeding, 
etc.), as well as on the strength and age of the patient." — Billroth. 



TUMOBS OF THE MOUTH. 877 

First. Fibrous Tumors — Fibroma. — The study of the fibromata 
begins with — 1. A tumor, the most common seat of which, as the 
whole body is concerned, is, beyond comparison, about the jaws. 
These tumors, which to the eye are composed of firm, interlaced 
fibrous tissue, are, to the touch, hard, yet to an extent elastic. 
Such growths spring from the periosteal tissue, and find a favorite 
location in the antrum. When unmoulded, as when springing 
from a free surface, they are superficially lobed, and, as a rule, 
are ovoid in form ; when occupying the sinus, they conform very 
much to the shape of the cavity, and are apt to retain the bony 
covering until they attain a size many times greater than the site 
from which they originate. In color, these tumors are a faintly yel- 
lowish white, pure white, or a very pale red ; in arrangement, the 
fibres are concentrically related, affording an expression of concen- 
tration, as if growing toward, rather than from, a centre. 

The diagnosis of this form of the fibromata lies in the isolation 
of the growth ; in its elastic hardness ; in the perfectly healthy and 
non-implicated appearance of the associate parts ; in the absence of 
pain; and in the tardy growth. Such a tumor is to be removed with 
an almost positive assurance of non-return. 

2. A second form of the fibromata is found in such close alliance 
with the first that no one might doubt the intimate relationship of 
the two, differing really alone from the first in the presence of a 
looser stroma, being what Rindfleisch, in his classification, would 
term "a connective-tissue tumor." This tumor, or rather this ex- 
pression of a common tumor, has not the same concentric develop- 
ment, seeming, in this respect, to be less resisted by the neighboring 
parts ; it does not infiltrate, bat yet is of eccentric rather than con- 
centric growth ; or, if not this, then the fibrous relation is irregular. 
This is the first expression of the fibro-plastic tumor of Lebert. 

3. The myomata of Yirchow. Advancing one step farther in 
the appreciation of the fibromata, we meet with those spindle-shaped 
cells, which induced Yirchow to give to the expression the name of 
myoma, and which, when possessed of more marked characteristics, 
constitute the fibro-sarcoma of Rokitansky. This is the fibro-re- 
curring tumor, an expression of which Mr. Miller speaks — see his 
" Principles of Surgery" — " as of a tumor ill defined, one which it 
may be doubted if it is not more properly classed when placed among 
the malignant condition, seeing they are found prone to return, after 
excision, with singular obstinacy." 

The eccentric fibrous tumor — fibro-plastic, fibro-recurring, myoma, 



878 ORAL DISEASES AND SURGERY. 

fibro-sarcoma — presents alterations of structure, from which, at a 
point unknown to the author, it passes into classification as sarcoma. 
Second. Sarcoma. — The sarcomata are so called from presenting 
on section a fleshy look. A pure myoma would be alone the sarcoma, 
if by flesh-like we meant muscle-like ; but by flesh-like has not been 
meant muscle-like ; hence to say what is and what is not a sarcoma, 
is with all writers merely an approximation. With such confusion — 
exposed in detail in the first edition of this work — our classification 
happily enables us to dispense. A sarcoma is what in that volume 
it was designated, and what it is now designated by Billroth, — " a 
tumor consisting of tissue belonging to the developmental series of 
connective-tissue substances (connective tissue, cartilage, bone), 
muscles, and nerves, which, as a rule, does not go on to the formation 
of a perfect tissue, but to peculiar degenerations of the develop- 
mental forms;" in other words, it is an expression of the fibromata. 
Rindfleisch distinguishes the sarcomata into " the round-celled 
sarcoma, the spindle-celled sarcoma, and the fibroma."* 

* " The granulation-like round-celled sarcoma (sarcoma globo-cellulare sim- 
plex) in its textural and structural relations is allied to the model of the 
tissue of granulations. To the naked eye, a yellowish or reddish, thoroughly 
homogeneous, elastically soft mass, at times extraordinarily like the roe of 
fishes, presents itself from the cut surface; by scraping with a knife-blade, 
we can obtain a scanty amount of juice, which is almost entirely clear, or 
contains but few cells. The cells are small, round, and contain comparatively 
large nuclei, of sharp contour, and provided with nucleoli. The protoplasm, 
as a rule, is present only in small amount, therewith entirely naked ; we 
must have recourse to hardening the tumor and coloring it with carmine, in 
order to make it generally distinct, and to convince ourselves that a cell-body 
actually belongs to each of the apparently free nuclei. 

" The structure of round-celled sarcoma deviates only in a quantitative rela- 
tion from the structure of granulations. The vessels in part are wider, thicker 
walled ; where these, however, break up into capillaries, they are just as deli- 
cate, frequently only built of a simple cell-layer, such as we saw in the vessels 
of granulations. The interspaces between the vessels are everywhere uni- 
formly tilled by the round cells and the scanty, soft, and formless basis-sub- 
stance of the germinal tissue. In rare cases one observes a higher organization 
of the whole, which reminds of the papillosities of granulations, namely, a 
radiated striation and a decided disposition of the mass of the tumor for cleav- 
ing in radiating directions. We will more intimately speak of this fascicu- 
lated round-celled sarcoma, which, by preference, proceeds from periosteum, 
at the proper time, as sarcoma ossificum. 

"The simple round-celled sarcoma proceeds most frequently from connect- 
ive-tissue membranes : the periosteum and the sheaths of the nerve-centres are 
its favorite situations; meanwhile, we must also be prepared occasionally to 



TUMORS OF TEE MOUTH. 879 

Another expression of this tumor is that classified and described 
by Mr. Paget as the myeloid, — so called from a resemblance to mar- 
meet it in other parts, especially upon the outer skin, upon mucous and serous 
membranes, even in glands. The simple round-celled sarcoma is closely 
allied to the small-celled spindle-celled sarcoma, and through this to fibroma, 
and manifoldly goes over into it. To this corresponds the relative benignity 
which marks just these tumors above all other round-celled sarcomas. 

" The lymphatic gland-like round-celled sarcoma (sarcoma lymphadenoides 
molle) owes its more limited consistence pre-eminently to the circumstance 
that its cellular elements are less intimately and immediately combined with 
each other than the cells of ordinary tissue of granulations. We can here 
obtain with facility, by scraping the cut surface, a juice with an abundance 
of cells, whose microscopic observation shows these latter to be round cells, 
which are distinguished by large, oval, slightly refractive nuclei, provided 
with one dot-like nucleolus. If we harden the tumor and tease out a thin 
section of it, we find between the cells a delicate intercellular net-work, which 
strongly reminds of the reticulum of the lymphatic follicles, the intestinal 
mucous membrane, and caro luxurians (proud flesh) This net-work spreads 
itself among the wide, thin-walled capillaries, and gives the whole structure 
a certain support, while on the other hand it permits the accumulation of an 
abundance of fluid beside the cells, and favors the isolation of the latter. 

lt The sarcoma under consideration most frequently proceeds from the sub- 
cutaneous, subfascial, and intermuscular connective tissue of the thigh. In 
the next place, the lymphatic glands must be designated as its preferred situ- 
ation. Here, however, the peculiar case occurs, that the uniformity of struc- 
ture could cause anatomists to regard sarcoma as a hyperplasia, though ever 
so monstrous, of lymphatic glands, while yet the clinical character (malig- 
nancy of high degree) exhibits a complete uniformity with the soft sarcoma. 

" There are several varieties of lymphadenoid sarcomas. The lipomatous 
sarcoma (sarcoma lipomatodes) shows the peculiarity that its cells are trans- 
formed into fat-cells by the infiltration of fat. This transformation always 
affects only a limited number of the existing elements; as, however, the 
sheen and size which the single cells attain deceive the eye, it may readily 
have the appearance as though at least the great majority of the sarcoma-cells 
had become fat-cells. Of any considerable similarity to genuine adipose tissue 
there can, nevertheless, not a word be said ; the want of uniformity of infil- 
tration, and the circumstance that we find very small and very large fat-cells 
confusedly intermingled and never united into little clusters, exclude all 
mistake for lipoma. 

"The mucoid sarcoma (sarcoma myxomatodes). It is a tolerably frequent 
occurrence to see here and there small portions of mucoid tissue in round- 
celled sarcomas. A translucent gelatinously trembling consistency betrays 
places of this kind already to the naked eye ; the microscope, as a rule, exhibits 
an abundant quantity of mucoid basis-substance, with numerous round, non- 
anastomosing cells imbedded. The mucoid softening of the basis-substance 
may be properly regarded as a secondary metamorphosis, to which all round- 



880 ORAL DISEASES AND SURGERY. 

row, — an expression so lacking a persistent individuality that, even 
according to the classifier himself, they vary from simple semi-fibrous, 
semi-marrow-like structure to those so heteroclitic that they seem 
to merge into the medullary. 



celled sarcomas are disposed. In as far, however, as this begins at an early 
period and extends over greater sections of a tumor, is the name ' mucoid 
sarcoma' justifiable. Nay, the mucoid tissue may so predominate, that we 
might be tempted to think of a completely mucoid tumor, a myxoma, if yet 
some unchanged places, especially, however, the young developments at the 
periphery of the tumor, and striking metastases, did not place its sarcomatous 
nature beyond doubt. An exceedingly rapid growth, which is said to pertain 
to mucoid sarcomas, may be illusively presented by this, that the mucus, 
because of its extraordinary capacity for swelling up, occupies a far larger 
space than does the scanty basis-substance of the sarcoma. 

" Mucoid metamorphosis and fatty infiltration not infrequently occur side 
by side, and just these tumors may attain a colossal volume. 

" Besides the loose connective tissue of the extremities, the subperitoneal 
connective tissue is also a favorite seat of mucoid sarcoma. 

" The large-celled round-celled sarcoma shows us an almost epithelial struc- 
ture of cells, besides a correspondingly large-meshed intercellular net. This 
tumor is very soft, like the white matter of the brain, and is, therefore, easily 
mistaken for the following species. 

" The alveolar round-celled sarcoma, Billroth (sarcoma medullare carcino- 
matodes) represents a further advance in the independence of the cells, which, 
upon the one hand, may be compared to the suppuration of an inflammatory 
texture; upon the other, however, reminds of that sharply-defined opposition 
between connective-tissue parts and the cellular apparatus, which we find in 
cancer. Characteristic of these forms is the occurrence of roundish balls of 
cells, which are no longer connected together by a proper basis-substance, but 
are taken up by a correspondingly large cleft in the continuity of connective 
tissue, like the pus-corpuscles in a small abscess. It is not said therewith 
that these cells are also externally like pus-corpuscles ; they are rather con- 
siderably larger, have vesicular, round nuclei, with bright nucleoli; and in 
this respect they approach more nearly to the epithelial condition, which, in 
individual cases, they even deceptively imitate. I esteem this of more con- 
sequence than is conceded to me at many hands, because I straightway pro- 
nounce the formation as a carcinomatous degeneration of the sarcoma (sarcoma 
carcinomatodes). According to my judgment, we must no longer hold to the 
opinion that the carcinomatous structure which presents the clinical charac- 
ters of carcinoma exclusively proceeds from the preformed division between 
connective tissue and epithelium. ' Stroma' and < cellular deposition' may 
also be produced in other ways, and 'epithelioid' is not yet 'epithelium,' 
although one might form conjectures as to why those cells, which loosen 
themselves in a more organic manner, slowly, and not suddenly, like pus-cor- 
puscles, from the mother-soil, always show this tendency to a more epithelial 
development. For this is just the difference between an actual suppuration 



TUMORS OF THE MOUTH, 881 

"A myeloid," says Mr. Paget, "like a fibrous tumor, may be either 
inclosed in a bone whose walls are expanded round it, or, more 

and this imitation, that at the present time we have yet no right to regard the 
eell-halls mentioned as elements completely separated from the nutrition of 
the hody. Their longer continuance without fatty degeneration gives us 
security for this. 

" Sarcoma carcinomatodes occurs at the most various points of the inter- 
mediary nutritive apparatus, most frequently in the medulla of hone, in the 
eye, in the subcutaneous tissues. An exceedingly malignant variety of this, 
distinguished by the pigment contained in its cells, is the so-called pigmentary 
cancer (sarcoma alveolare pigmentatum). The external nature and the pre- 
liminary diagnosis is determined upon the one hand by the great softness of 
the tumor, upon the other by the dark discoloration. If we examine it micro- 
scopically, we find, besides the alveolar structure, which appears as the sum- 
mit of development, more or less extended parts, which bring to our view 
former stages of the development of the tumor. The most common is an infil- 
tration of the connective tissue with pigmented round cells, which is directly 
transformed by depot-like accumulations into the medullary formation. In 
other cases a declared sarcomatous structure, and indeed more frequently 
the spindle-celled than the round-celled, has evidently existed for some time, 
ere it came to the formation of the characteristic cell-balls. Hence we are 
led to the opinion that the melanoses in general are closely allied to each 
other, a view which we will follow more closely upon the occasion of speak- 
ing of the commonly-called pigmentary sarcoma. 

" Spindle-celled Sarcoma. — The small-celled spindle- celled sarcoma (s. fuso- 
cellulare durum) occupies the same position among the spindle-celled sarcomas 
that the granulation-like sarcoma does among the round-celled ones. It 
deviates the least from the model of inflammatory new formations, because it 
very accurately copies after that spindle-celled tissue of recent cicatrices 
which represents the regular intermediate degree between the tissue of granu- 
lation and the tissue of cicatrices. The characteristic textural element is a 
short and narrow spindle-cell with an elongated roundish nucleus, with or 
without nucleoli. The protoplasm of the cell is finely granular, most dense 
in the neighborhood of the nucleus ; a limitary membrane is nowhere to be 
perceived with certainty ; such a one is certainly wanting in the smaller cells. 

"In the mass of the tumor, the spindle-cells are very regularly fitted 
together in such manner that the pointed angle, which remains between the 
tapering ends of two elements lying side by side, is filled out by the tapering 
end of a third, which is respectively situated behind and before them. There 
is nothing to be seen of the intermediate substance ; in any event there is no 
more present than a tissue of granulation ; but this minimum quantity, which 
properly is only a formless, sticky cell-cement, must also not be wanting in 
the spindle-celled tissue. By its aid and by virtue of the just-mentioned har- 
monious arrangement arise lines of cells ; there are formed larger and smaller 
bundles, which furnish the next higher structural element of the spindle- 
celled sarcoma. Its arrangement in the rarest cases is radiated, so that united 

55 



882 ORAL DISEASES AND SURGERY. 

rarely, it is closely set on the surface of a bone coDfused with its 
periosteum." The sketches of fibrous tumors pictured in his Sur- 

bundles go out from a centrally located point ; more frequently even a greater 
number of such points of departure are given, and the various systems of 
bundles interweave in the various directions determined by the location of 
these points ; generally, however, we are not able to specify any positive prin- 
ciple according to which the blending of the bundles into a whole is accom- 
plished, and find upon every transverse section bundles which are divided 
longitudinally, others transversely, and yet others in a more or less oblique 
direction. The determining influence for the course of the cell-rows has been 
sought in the course of the vessels, yet incorrectly ; for although we never 
fail to find in the larger fasciculi of the tumor a larger vessel running in the 
same direction, yet this is only the case in the larger fasciculi. More remotely 
the vessels break up entirely retiform as in other parenchymas, breaking 
through the cell-rows in all imaginable directions. Withal, the collective 
vessels, even the larger of a sarcoma, have almost no proper walls, and pre- 
sent themselves upon transverse sections of a hardened preparation like exca- 
vated canals and perforations. 

" The small-celled spindle-celled sarcoma has a preference for the connective- 
tissue membranes, fascias, vascular and nervous sheaths, the subcutaneous and 
submucous connective tissues ; in short, it has the same seats as the fibromas ; 
it is also often enough (for example, upon the uterus) found beside fibromas. 
In addition, we can point out in every small-celled spindle-celled sarcoma 
such places, where the spindle-celled tissue is transformed into fibrous connect- 
ive tissue ; there are tumors which are composed half of the one and half of 
the other, so that a relationship close to an identity of these tumors must be 
accepted. 

" The. large-celled spindle-celled sarcoma is anything but simply a variety of 
the small-celled. The important point in which it is distinguished from the 
latter is the excessive development which falls to the lot of the cells in oppo- 
sition to all the other constituents. The spindle-cells may attain the very 
respectable thickness of 0.015 /// , and so enormous a length, that the two ends 
in magnifying by 200 diameters are separated by the breadth of three fields 
of the microscope. The cell is thickest where the large, elongated roundish 
nucleus, supplied with bright nucleoli, is situated. The protoplasm in the 
neighborhood of the nucleus is finely granular and soft, more homogeneous 
towards the circumference ; a cell-membrane cannot be shown, only the pro- 
cesses occasionally show so considerable a firmness and so strong a refractive 
power that they must be regarded as protoplasm having become rigid. As 
to the number of processes of the spindle-cell, two constitute the rule ; three 
or more exceptionally occur, which bestows upon the cell the character of a 
stellate cell. (Virchow.) 

"In real typical spindle-celled sarcomas, these cells combine into larger 
strands, leaves, and fasciculi, which either radiate in straight lines towards all 
directions from a common basis (radiary sarcoma, foliated sarcoma), or they 
manifoldly interweave (trabecular sarcoma). These tumors may attain a very 



TUMORS OF THE MOUTH. 883 

gical Pathology, page 406, might, he says, be repeated for myeloid 
tumors. 



considerable circumference, without a further modification of their texture or 
structure occurring. The enormous growth of the cells occurs in a certain 
measure vicariously for the seasonable development of fibrous intercellular 
substance; and if with Max Schultze we wish to see in the latter only trans- 
formed protoplasm, we have here before us the case of a massively produced, 
but not applied, building-material. 

" The large-celled spindle-celled sarcomas proceed from fasciae and mem- 
branes, rarely from the interstitial tissues of glandular organs. They are of 
limited malignancy, and are, as a rule, once for all removed by a seasonable 
extirpation. Of course they must not be mistaken for radiating cancers and 
medullary sarcomas. 

" As an individual variety of the large-celled spindle-celled sarcoma, there 
is a tumor to be designated which is observed upon the skin of the cheek, 
and essentially depends upon a combination of the round-celled with the 
spindle-celled type. Broad fibrous lines of spindle-shaped cells go out from 
one or more points ; where these fibrous lines diverge, the round-celled tissue 
fills out the spaces. 

" The pigmentary sarcoma (s. melanodes) by far most frequently proceeds 
from the choroid coat of the eye, then from the outer integument : both points 
at which normally a certain pigmentary infiltration of the cellular elements 
is already observed. We comprehend this phenomenon, as a rule, in such 
manner, that in the pathological new formation a vital property of those cells 
is maintained, from which this proceeds. Yet precaution is to be recommended 
here. The metastatic foci of tumors, also, which are not rare in the pro- 
nounced malignity of pigmentary sarcoma, show the same disposition to pig- 
mentary infiltration, although they develop at points where there is not a word 
to be said of physiological pigmentation. This transfer of an entirely local 
peculiarity to the secondary tumors has been used as well for as against this 
opinion: for it, by those who believe that the metastasis is accomplished by 
the transfer of bodily constituents from the primary foci of development to 
another spot; against it, by those who believe in a constitutional disease- 
producing tumor, which, wherever it produces tumors, produces black tumors. 

" I regard it as imperative in this case to keep two things as sharply defined 
as possible: 1, the incitation of metastasis by emigrant cells of the primary 
tumor ; and 2, the pigmentation of the secondary tumor. As to 1, I point to 
the suppositions and doubts expressed in \ 120; as to 2, w r e must constantly 
remember that all the cells of a melanotic tumor are colorless in their youth. 
That these are the direct offspring of the emigrant cells of the primary tumor, 
no one will assert; they are rather undoubtedly local products, and if they yet 
become colored, we must necessarily refer this coloring to a constitutional dis- 
position, which is independent of the location of the primary tumor. With 
this the etiological experiences also agree, which point out at least for the 
outer skin a superfluous formation of pigment as the predisposing cause This 
asserts itself either in the production of black warts, which may directly 



884 ORAL DISEASES AND SURGERY. 

These two kinds of tumors are described as being equally common 
to the jaws, both the superior and inferior. 

degenerate to melanotic sarcomas, or into now a more diffused, now a more 
circumscribed, brown and black spotting of the skin. The peculiar predispo- 
sition of creatures not at all pigmented, as, for example, the white horse, to 
sarcoma melanodes, gives more the impression of a vicarious deposition of 
pigment, accumulating at one point, and therefore combined with a certain 
irritation of the tissues. 

" In all pigmentary tumors the cells are the exclusive carriers of the pig- 
ment. "We have devoted a particular consideration to the histological detail 
of pigmentary infiltration. I referred for the case of pigmented tumors the 
opinion of a pigmentary formation, derived only from hemorrhages, and for 
this presented the view that the question here is about the taking up of the 
coloring-matter of the blood from the blood. What inclines me hy prefer- 
ence to this assertion, leaving out of consideration the deficient proof of a 
hemorrhagic production, is an observation upon the first origin of pigment in 
such tumors as had existed for some time as simple medullary sarcomas, then 
to be transformed into melanotic tumors, and as such to form their recurrences 
and metastases. We can here not infrequently convince ourselves that the 
first traces of pigmentary infiltration were visible at the epithelia of tJte 
vessels. Can this be interpreted otherwise than that the epithelia have taken 
up the diffused coloring-matter from the blood? that it has been condensed in 
them and precipitated in granular form ? And when afterwards entirely the 
same formation of pigment shows itself beside the vessels, when finally it 
occur? in the whole parenchyma of the tumor, according to my judgment 
Ave may not doubt that it is also accomplished here in the same manner as 
upon the epithelia of the vessels, by taking up the diffuse coloring-matter from 
the blood. 

"In view of the discussed general pathological relations of melanotic 
tumors, their anatomical position falls more into the background. That 
which is commonly called pigmentary cancer has been already described 
as round-celled alveolar or medullary pigmentary sarcoma. The remaining 
pigmentary tumors, as a rule, belong to the spindle-celled sarcomas. These 
are generally of more compact consistency, and of foliated or fasciculated 
arrangement. In the decided tendency to form superficial elevations, tuber- 
osities, and fungi, which otherwise is also peculiar to round-celled sarcoma. 
a contrast to be well noticed is expressed against destructive carcinomas. In 
regard to color, the above-mentioned principle is the measure of the pigment- 
less youthful state of the constituent elements. There are pigmentary sar- 
comas of considerable size, which first of all only betray their true character 
by a black and brown striation, a spotted or dappled appearance. The deep 
brownish-black sepia color only represents the highest degree of pigmentary 
infiltration. 

'• A fibromatous constitution, according to Virchow, only pertains to the 
above-mentioned black fungosities of the white horse, which also distinguish 



TUMORS OF THE MOUTH. 885 

" When the myeloid is inclosed in bone, the tumors usually tend 
to the ovoid or spherical shape, and are well denned, if not invested 

themselves by their benignity essentially from all other constantly malignant 
melano-sarcomas. 

• L Fibrous Sarcoma. — The fibroids. I cannot separate the fibroma from the 
sarcomas. With the same correctness with which we sought the paradigm 
of round- and spindle-celled sarcomas in the round- and spindle-celled tissues 
of the inflammatory new formation, will we seek and find the model of fibro- 
matous texture in the completed cicatricial tissue. 

" The common fibroid (desmoid) consists of a fibrous, reddish-white, tightly 
elastic, and so dense, compact, even hard tumor, that in cutting it it creaks 
under the knife. The textural elements are those of cicatricial tissue. If we 
tear off a minute fibril from the cut surface and pull it to pieces, we are aston- 
ished at the enormous volume which the fibril assumes, that is to say, the 
enormous number of more minute fibrillse into which it may be broken up. 
The microscope, however, tells us that each of these smaller fibrils is also 
yet a complication of very delicate, minutest fibrils, only marked by a single 
but sharply-defined line. Like as a well-braided tress occupies far less space 
than a dishevelled braid of hair, although both contain the same amount of 
hair, so we must also here represent to ourselves that in the fibroma the fine 
and the finest fibrils are extraordinarily closely pressed together, until they 
are loosened by our needles, and then occupy an astonishing amount of space. 

" Between the fibrils, which are formed of glue-yielding substance, and 
have the significance of a fibrous intercellular substance, the cells are visible : 
as a rule, small, oval structures, with shining nuclei. Virchow has been 
induced, by the great similarity of these with smooth muscular fibre, to set 
up a fibro-muscular tumor as a particular variety of fibroma. I am very far 
from wishing to bring this resemblance into question ; a determination of 
the histological boundary between spindle-cells and smooth muscular fibres is 
in fact a very precarious thing ; meanwhile, I regard it as conformable to 
continue for the present the comparison of sarcoma with the inflammatory 
new formation, {he sarcoma-spindles with the cicatricial spindles. By this 
we obtain a useful foundation for understanding the collective structural 
elements occurring in fibroids ; for what has been hitherto described only 
constitutes the principal mass of the tumor ; besides which we find, 1, rows of 
spindle-cells, which run through the tumor in various directions ; 2, round- 
ish foci of germinal tissue, which are here and there sprinkled into the con- 
tinuity of the fibres. I regard both as transition formations, from which the 
fibrous tissue is developed in entirely the same way as the cicatrix from the 
germinal and spindle-celled tissues. I found numerous fibromas upon a uterus, 
of which the larger principally consisted of fibrous tissue, the smaller ones 
almost only of spindle-celled tissue. 

" The cut surface of the tumor deserves an especial consideration. The 
intimate intertwining and interweaving of the fibrous lines bestows upon it a 
peculiar impress. Microscopic examination particularizes the appearance 
which the naked eye perceives, without acquainting us with the cause of the 



886 ORAL DISEASES AND SURGERY. 

with distinct thin capsules ; seated on bone, they are much less de- 
fined, less regular in shape, and often deeply lobed. They feel like 
uniformly compact masses, but are in different instances variously 
consistent. The most characteristic examples are firm, and (if by 
the name we may imply such a character as that of the muscular 
substance of a mammalian heart) they may be called fleshy. Others 
are softer, in several gradations, to the softness of size gelatin, or to 
that of a section of granulations. Even the firmer are brittle, easily 
crushed or broken; they are not tough, nor very elastic, like the 
ordinary fibro-cellular or fibrous tumors, neither are they grumous 
or pulpy, neither do they show a fibrous or granular structure on 
their cut or broken surfaces; these tumors are smooth, uniform, 
compact, shining, succulent, with a yellowish, not a creamy fluid. 
A peculiar appearance is given commonly to them by the cut surface 
presenting blotches of dark or livid crimson, or of a brownish or a 
brighter blood color, or of a pale pink, or of all these tints mingled 
on the grayish-white or greenish basis-color. [In a foot-note, Mr. 
Paget quotes from Lebert, who says the greenish-yellow color that 
may show depeuds on a peculiar fat, xanthose.] The tumors may 
all be pale, or have only few points of ruddy blotching, or the cut 

arrangement. For the arrangement of the mass of some fibromas the cir- 
cumstance appears of importance, that the new formation particularly local- 
izes itself upon the vessels and nerves of a part. Thus Billroth has described 
a fibroid of the eyelids, and given it to me for subsequent investigation, 
which consists of numerous sausage-like cylinders, in whose axes the remains 
of small nerve-trunks are distinctly visible. Based upon this, Czerny has 
lately separated a particular group of sarcomas as ' plexiform tumors,' be- 
cause beside the nerve-branches he also proclaimed the ramification of the 
vessels as the occasional cause of these striking structural relations. It must 
be marked as the most striking formation belonging to this class, when the 
collective vessels of a tumor, in itself myxomatous, are surrounded by a rela- 
tively thick sheath, upon which we can throughout recognize a round-celled 
nature. An influence of the course of the vessels upon the course of the 
fibrous bundles cannot be established in ordinary fibromas. The view is 
much more probable to me. that in the peculiarly central growth of the 
fibroma the new tumor-mass is inserted between the existing fibrous rows, 
pressing them asunder, and thus the incomplete stratified structure of the 
tumor is conditioned by repeated separation of these fibres, and not by 
superposition. 

" Fibroma correctly ranks as one of the benign new formations. We will 
learn to know the uterus as its preferred seat, and at the same time a series 
of interesting modifications of the anatomical appearance just sketched." — 

BlNDFLEISCH. 



TUMORS OF THE MOUTH. 887 

surface may be nearly all suffused, or even the whole substance may 
have a dull modena or crimson tinge, like the ruddy color of a heart, 
or that of the parenchyma of a spleen. Many of what have been 
named spleen-like tumors of the jaws are of this kind. The color 
they present is not due merely to blood in them ; some of it is ap- 
propriate to their texture, as is that of the spleen or that of granu- 
lations, and it may be quickly and completely bleached with alcohol." 
The following are the microscopic appearances pronounced pecu- 
liar to the myeloid growth, being imitated in no other morbid 
structure : 

1. Cells of oval, lanceolate, or angular shape, or elongated and 
attenuated like fibre-cells, or caudate cells, having dimly-dotted con- 
tents, with a single nucleus and nucleolus. 

2. Free nuclei, such as may have escaped from the cells, and, 
among these, some that appear enlarged and elliptical, or variously 
angular, or are elongated toward the same shapes as the lanceolate 
and caudate cells, and seem as if they were assuming the character 
of cells. 

3. The most peculiar form : large, round, oval, or flask-shaped, or 
irregular cells or cell-like masses, or thin disks of clear or dimly- 
granular substance, measuring from one three-hundredths to one- 
thousandth of an inch in diameter, and containing two to ten or 
more oval, clear, and nucleolated nuclei. 

Corpuscles such as these, irregularly and in diverse proportions 
imbedded in a dimly-granular substance, make up the mass of a 
myeloid tumor. They may be mingled with molecular matter, or 
the mass they compose may be traversed with filaments or with 
bundles of fibro-cellular tissue and blood-vessels, but their essential 
features (and especially those of the many-nucleated corpuscles) are 
rarely observed. 

Many varieties of aspect (as remarked by Mr. Paget) may thus 
be observed in myeloid tumors, and beyond these they may even be 
so changed that the microscope may be essential to their diagnosis. 
After they partially ossify, well-formed cancellous bone being de- 
veloped in them, cysts, also filled with bloody or serous fluids, may 
be formed in them, occupying much of their volume, or even almost 
excluding the solid texture. 

This author notes a case in which he lately amputated the leg of 
a woman, twenty-four years old, for what was supposed to be a 
cancerous tumor growing within the head of the tibia. She had had 
pain in the part for eighteen months, and increasing swelling for ten 



888 ORAL DISEASES AND SURGERY. 

months, and it was plain that the bone was expanded and wasted 
around some soft growth within. 

On section, after removal, the head of the tibia, including its ar- 
ticular face, appeared expanded into a rounded cyst or sac about 
three and a half inches in diameter, the walls of which were formed 
by this flexible bone and periosteum, and by the articular cartilages 
above ; within there was little more than a few bands or columns 
of bone, among a disorderly collection of cysts filled with blood, or 
blood-colored serous fluids. The walls of most of the cysts were 
thin and pellucid; those of others were thicker, soft, and brownish- 
yellow, like the substance of some medullary cancers, a likeness to 
which was yet more marked in a small solid portion of tumor, 
which, though very firm, and looking fibrous, was pure white and 
brain-like. 

No one, Mr. Paget says, who examined this disease with the naked 
eye alone, felt any doubt that it was an example of medullary cancer, 
with cysts abundantly formed in it. But, on minute investigation, 
none but the elements of the myeloid tumors could be found in it ; 
these, copiously imbedded in a dimly-granular substance, appeared 
to form the substance of the cyst-walls, and of whatever solid ma- 
terial existed between them. The white brain-like mass was appa- 
rently composed of similar elements in a state of advanced fatty 
degeneration, but neither in it nor in any other part could be found 
a semblance of cancer-cell. 

No mention is made of the return of the disease ; it would seem 
that, in the present state of our knowledge of cancer-growths, it 
would have been a very difficult matter to class such a tumor with 
the non-malignant. It certainly was very heteroclitic in character, 
and whatever we individually may feel disposed to think of such a 
structure, it serves to exhibit the merging of the commonly deemed 
benign into the malignant, and the relationship of the two. A con- 
sideration of such cases as this should serve to keep the practitioner 
on his guard, preventing his being too confident in any prognosis 
he may give to a patient. 

An epitome of the myeloid may thus be presented : 

They are a class of fleshy tumors called by M. Lebert fibro-plastic, 
because, he says, they are made up of fibre-cells. They are called 
myeloid by Mr. Paget, because he thinks they resemble marrow 
much more than fibrous tissue. 

In character, " they vary from simple semi-fibrous, semi-marrow- 



TUMORS OF THE MOUTH. 889 

like structures to those so heteroclitic that they seem to merge into 
the medullary." 

Their favorite seat seems to be about the bones, either intra or 
extra, being perhaps more common in the maxillae than in any other 
osseous structures. 

They are growths which usually occur singly; they are more fre- 
quent in youth, and very rare after middle age ; they generally grow 
slowly and without pain, and usually commence without any known 
cause, such as injury or hereditary disposition. 

According to Mr. Paget, they rarely, except in portions, become 
osseous ; they have no proneness to ulcerate or protrude ; they seem 
to bear even considerable injury without becoming exuberant ; they 
may shrink or cease to grow ; they are not apt to recur after com- 
plete removal, nor have they in general any features of malignant 
disease. 

Since writing the above the author has accidentally fallen upon 
a classification of the tumors of the upper jaw, made by Mr. Hancock. 
After alluding to various classes, he says, "In addition to these, 
Mr. Paget adds what he terms myeloid tumors of the part ; but while 
the examples he quote resemble on the one hand so much the fibrous, 
on the other the medullary tumors, their true character, whether 
innocent or malignant, is so very doubtful that I should hesitate in 
admitting them as a distinct class." 

Epitome. — Fibrous tumors proper, and the fibro-plastic, have 
general features in common, — that is, they belong to the class of 
sarcomatous growth ; but then in a pathological sense they have such 
differences that an epitome, at least, of their history should be reviewed 
by us. 

In some instances, fibrous tumors are seen under the microscope 
to have a concentric development: this species is slowest of growth, 
is most benign, and never attains any great size. 

In another species the fibres interlace in a most complicated and 
irregular manner. This kind attains the largest size, and seems 
striding toward the heteroclitic. 

A third class consists of an aggregate of nodules, and is compared 
by Dr. Humphrey to a conglomerate gland; the tumor being made 
up of small masses closely compressed together, having an uneven, 
knotty outline. 

Fibrous tumors affecting the bones (Braithwaite) are usually found 
upon those of a spongy nature, upon the ends of the long bones, the 
phalanges, pelvis, and in the jaws. " So far," says this author, " as I 



890 ORAL DISEASES AND SURGERY- 

have met with them, they are confined to the exterior of the lower 
jaw, growing from the periosteum and creeping along the surface of 
the bone in such a manner as to prove almost to a certainty that 
they originate in some morbid condition of the periosteal fibres. The 
bone underneath these tumors may suffer absorption in consequence 
of the pressure produced, but does not seem to be affected in any 
other way. They appear upon the maxillary bone more frequently 
than upon any other part of the skeleton. On the lower jaw they 
spread along the ramus, encircling it beneath and on the sides, so 
that the bone is almost concealed by the tumor. In some instances 
they form within the substance of the jaw, probably from the alveolo- 
dental membrane, and as they increase, the walls of the bone become 
spread out over them. They grow up around the teeth, and when 
they project into the mouth may be soft and fungous."* 

In some instances the fibrous tumors of the jaws exhibit a semi- 
cartilaginous structure, and now and then fibres or plates of bone 
are formed in various parts of them. The progress of the disease 
is well illustrated by a series of tumors of the jaws in the College 
of Surgeons, London, from the museum of the late Mr. Liston. 
These preparations serve to show how necessary it is to bear in 
mind the mode of growth of these periosteal fibrous tumors of the 
jaws, because from their disposition to creep along the surface of 
the bone, whether it be an endosteum or periosteum, they are liable 
to return after removal, unless the immediately adjacent as well as 
affected parts be excised. The histories attached to the specimens 
teach that very large fibrous tumors, both of the upper and lower 
jaws, together with the bones on which, or in which, they grow, may 
be successfully removed. 

Cysto-sarcoma, an expression as implied by the prefix, is a tumor 
of only semi-solidity, its interior, or stroma, being made up of cysts 
and fleshy substance. These cysts are original formations, and not 
of secondary character, — that is, they are not the result of molecular 
disintegration. They are lined sacs, having a distinct secretory 
membrane. Miller describes the contents of these cysts as widely 
differing, and which every one must have observed : " They are more 
or less fluid, sometimes a clear glue}^ liquid, sometimes a gelatinous, 
pale mass of semi-solid consistence, elastic, and projecting beyond 

* Presenting this phase, the tumor may be classed with the epulic, but it 
will be seen that on this account there need be no confusion. Many epulic 
tumors are osteo-sarcomatous. 



TUMOBS OF THE MOUTH. 891 

the level of the cut cyst on a section being made ; sometimes a solid, 
consisting of a fibrous deposit, organized very imperfectly, if at all ; 
sometimes of an exanthematous or poppy consistence, as in many 
encysted tumors ; sometimes, but more rarely, a dark fluid, like 
printers' ink, is contained; sometimes blood is mingled with the 
contents, either in the solid or in the coagulated form." 

The very nearest approach, however, made by cysto-sarcoma to 
the explainable cysts, is in that class, very well named by some one, 
as I remember to have seen, the " cysto-succulent." These are sar- 
comatous tumors, the stroma of which is made up of very loose 
fibro-cellular tissue. They might well, in their contents, be likened 
to a watermelon, solid enough on section, but compressible to a 
few shreds. The fibrous contents of the stroma are, however, 
always a distinguishing sign. These tumors are very rare, and 
particularly so about the bony structures. 

Miiller has described a variety of these cysts of sarcomatous 
growth, which he calls cysto-sarcoma phyllodes. " The tumor," he 
says, " forms a large firm mass, with a more or less uneven surface. 
The fibrous substance, which constitutes a greater part of it, is of a 
grayish-white color, extremely hard, and as firm as fibro-cartilage. 
Large portions of the tumor are made up entirely of this mass, but 
in some parts are cavities or clefts, not lined with a distinct mem- 
brane (an exception to the rule in cystic tumors). These cavities 
contain but little fluid, for either their parietes, which are hard, like 
fibro-cartilage, and finely polished, lie in close apposition with each 
other, or a number of firm, irregular laminae sprout from the mass 
and from the walls of the fissures, or excrescences of foliated or wart- 
like form sprout from the bottom of the cavities and fill up the in- 
terior. These excrescences are perfectly smooth on their surfaces, 
and never contain cysts or cells. The laminae lie very irregularly, 
and project into the cavities and fissures like the folds of the psal- 
teriuni in the interior of the third stomach of ruminant animals. 
Sometimes the laminae are but small, and the warty excrescences 
from the cysts are very large, while in other instances both are 
greatly developed." 

Cartilaginous, or the enchondromatous tumors of Miiller, might, 
perhaps, for all practical purposes, be classified with the sarcomatous, 
for while it might demand some little stretch of the imagination to 
convert a cartilage into looking like a fleshy mass, yet surgically the 
species are very much alike,— that is, both are reasonably benign, 



892 ORAL DISEASES AND SURGERY. 

both are little amenable to the action of the sorbefacients, and both 
are better treated by the knife than in any other way. 

As we understand the osteo-sarcomatous tumors proper to be out- 
growths associated commonly with periosteal membranes, so we are 
led naturally to ask ourselves as to the cause of their formation. 
This may be conceived to be twofold : first, as the result of local 
irritation ; second, as the result of constitutional conditions ; and, 
still again, we may combine these two, laying the predisposing cause 
on the one and the exciting on the other. 

The attention of the author was once directed by William Gibson, 
late Professor of Surgery in the University of Pennsylvania, to a 
case markedly illustrative of this latter condition. An old gentleman, 
Mr. F., seventy years of age, was struck on the cheek by a stone. 
He soon had growing from the site of the injury a tumor, diagnosed 
by Professor G. as osteo-sarcomatous. The growth of the body was 
so rapid and so formidable as to incline to the view of its intimate 
relationship with malignancy. No one would doubt the twofold 
relation of such a tumor. 

When osteo-sarcoma takes on this rapid growth, its innocency 
may always be doubted ; when the development is slow and regular, 
and particularly if the origin can be traced to some local irritant, 
extirpation may be expected to result in a cure. 

Osteo, or simple sarcomatous tumors of the sinus maxillare, should 
not be mistaken, as has too often been the case, for polypi of the 
nares. It sometimes happens that these tumors, particularly the 
softer kinds, find their way through the outlet of the sinus into the 
nostril, and there simulate very closely a common fibrous polypus; 
such tumors have been often highly aggravated by operations founded 
on such mistaken diagnosis. Again, polypi of the nostrils may find 
their way through the same passage into the sinus, and, enlarging, 
represent very fair]} 7 the ordinary sarcomatous tumor of that cavity. 
Now, pathologically speaking, being about one and the same thing, 
it would be little difference where or how the growth should develop, 
but as operative proceedings are concerned, a mistake of the kind 
becomes quite an awkward matter. 

As regards changes common to the sarcomatous tumors, they 
may be considered under the heads of softening, suppuration, and 
malignant degeneration. 

Softening, as inferred by Dr. Humphrey, appears to take place in 
two ways : 

First, as a chronic process, affecting some circumscribed portion 



TUMORS OF THE MOUTH. 893 

of the tumor, which is usually at or near the centre. The change 
is observed to commence with a slight discoloration, a yellowish or 
dark tinge, which is followed by a loosening or incipient disintegra- 
tion of the structure ; at the same time a line of demarkation is formed 
around the altered portion, which becomes separated, like a seques- 
trum, from the surrounding mass. Both the detached portion and 
the cavity are at first rough and thready on their opposed surface ; 
the former undergoes still further disintegration and solution, be- 
coming broken up into a number of smaller fragments, which float 
about in a dark, dirty, turbid fluid, and which may ultimately dis- 
appear. 

The process of destruction may go on in the adjacent portion of 
the tumor, enlarging the central cavity till the whole is reduced to 
a fluid or a semi-fluid mass, walled in by the capsule of the tumor, 
which now stands in the relation of a cyst-wall to the disorganized 
contents. 

In some cases the softening process is completed without extend- 
ing the circumference ; the ragged processes hanging into the interior 
of the cavity are removed. The latter acquire a smooth lining, and 
look like a simple cyst lying in the cavity of the tumor. 

A second mode in which softening takes place is more rapid and 
diffused, the whole or the greater portion of the tumor being affected 
at once. The change commeuces with the infiltration into the mass 
of a serous fluid, whereby its texture is loosened and its components 
separated ; at the same time the tissue of the tumor is softened, and 
interstitial absorption is set up in it. 

As the result of these processes combined, the tumor is soon 
broken up into detached fragments, and reduced to a diffluent pulp, 
or it may be completely liquefied. These changes, Dr. Humphrey 
suggests, " are occasioned by some altered nutrition analogous to 
inflammation; they may be induced by some accidental cause, as an 
injury ; nevertheless they are not necessarily attended with any 
constitutional disturbance at all corresponding with the extensive 
destruction which is in progress." 

Suppuration. — This is very rare; it may commence internally, or 
progress from without inward. 

Cancerous Degeneration. — The general conditions and features 
of such degenerations will find consideration in the succeeding chap- 
ter. Just here, however, a second cancerous relation may be alluded 
to, namely, the existence of compound tumors. Dr. Lewis relates a 
case where melanotic cancer was deposited in the stroma of a fibrous 



894 



ORAL DISEASES AND SURGERY. 



tumor, and Dr. Humphrey describes a large fibrous tumor completely 
enveloped in cancer. 



Fig. 274. — Osteo-Sarco- 
matous Tumor. 




Fig. 275. — Cysto-Sarcoma. 




The tumor represented in Fig. 274, from the person of an old 
woman, commenced within the antrum, and progressed four years 
before causing death. In character it was fibro-plastic, with here 
and there osseous masses. 

Fig. 275 represents a cysto-sarcoma. It is a section of the dis- 
eased lower jaw of a man aged about thirty. Death occurred within 
a vear, from return of the disease. 



CHAPTER XLIII. 

THE TUMORS OE THE MOUTH. 

THE NON-EXPLAINABLE TUMOKS, 

Here again, did we know where benignancy ends and where 
malignancy begins, our chapter might have a different heading; but, 
knowing that expressions of the fibromata will as surely progress to 
the destruction of a patient as any epithelial foundationed tumor 
which histology describes, it is impossible to do otherwise than 
place all such tumors under a common head. 

For convenience, however, we continue the study of the remaining 
tumors under the familiar term carcinoma, yet meaning by it nothing 
different from an expression of the vice cancer. 

Carcinoma, as the term has become identified with clinical im- 
pressions, would seem to be a condition isolated entirely from such 
as we have studied, inasmuch as it is a disease considered to be 
of a peculiarly malignant and rapid character; such differences, 
however, find explanation, as has been remarked in the preliminary 
pages, in the circumstances of the individual, and in the character 
of the disease itself. 

Carcinoma, according to the classification of Fische, which, as well 
as any other, we may adopt, is a word derived from the Greek xapxi- 
vo«r, signifying a "crab ;" it applies to a family of expressions which 
embrace the different forms of what, by the usual classification, is 
recognized as cancer. 

Primarily, if a real difference exists between a cancer proper and 
the conditions just considered, there should exist a distinctive some- 
thing to typify it.* Does this something appear ? In the foot-notes 



* " The exposition of general points of view concerning the nature, the 
origin, and the relationship of the so-called « carcinoma, 1 will form the chief 
contents of this section. By ' carcinoma' we understand a new formation 
destroying the organs of the body, after extirpation commonly recurring 
and undergoing metastasis, therefore malignant. These properties certainly 

( 895 ) 



896 ORAL DISEASES AND SURGERY. 

from Rinclfleisch and Billroth, the subject is discussed ; let the reader 
acquaint himself with these latest teachings of two of the most 

pertain, as we have seen, also to certain histoid tumors ; and it were exceed- 
ingly desirable, if there were a positive anatomical characteristic by which 
we could recognize carcinoma as such, and could distinguish it from other 
destructive and malignant new formations. We have now become accus- 
tomed, and to-day we yet hold fast this custom, of regarding a certain peculi- 
arity of structure, the so-called alveolar structure, as a necessary requisite 
for the diagnosis — cancer. By this we wish to say that we seek for the sub- 
stance of the carcinomatous degeneration in a deposition in foci of cells 
advancing in fixed directions, which necessarily tends to this, that we must 
grant to the parenchyma of the organ in process of destruction, which remains 
between these cellular depots, the form of a framework, a trabecular or net- 
work (stroma), whose meshes (alveoli) are determined by the form and size 
of the deposited aggregations of cells. It is manifest that this structure is 
particularly fitted to lodge large amounts of free cells, which we must 
regard as the most effective stimulus as well for the local growth of a 
tumor as for the infection of the entire organism. The seeming arbi- 
trariness with which we proclaim the alveolar structure as the anatomical 
criterion of cancer, consequently, receives its justification ; but a new diffi- 
culty arises, when we reflect that then the alveolar sarcomas must also be 
designated as carcinomas ; tumors, therefore, whose ' permeation by cellu- 
lar heaps' (' Durchsetztsein mit Zellenhaufen') we believed we ought to 
assimilate with the suppuration of inflammatory tissues. I accept this con- 
sequence, and thereby place myself upon the platform of those who under- 
stand by carcinoma in essentials a clinical character that is anatomically but 
imperfectly expressed ; i.e., only in the obligatory alveolar structure. 

" The greater number by far of carcinomas proceed primarily either from 
the epithelial- clad surfaces of the body, from the skin and mucous membranes, 
or from the secerning glands. They depend, upon an abnormal growth of the 
epithelial tissue. We may say that an ingrowing of epithelium into the 
sub-epithelial layer of connective tissue of membranes or into the interstitial 
connective tissue of glands forms the fundamental processes in these carci- 
nomas. The nature and manner of the ingrowing is extraordinarily various. 
The whole impression made by a carcinomatous destruction — for example, the 
observation of a vertical section by a low magnifying power — appears to justify 
the opinion that in them the question is about a diseased imitation of those 
histological processes which precede the development of glands with excre- 
tory ducts ; namely, here as there we see aggregations of epithelial cells, 
which proceed from the under surface of the epithelium in the form of cones 
or strands, and insinuate themselves between the separating filaments of the 
connective tissue. Active processes of division also show themselves in the 
elements constituting the cell- aggregations, so that in both of these principal 
points an undeniable uniformit} 7 with glandular growth is present. Never- 
theless, the view that the carcinoma formation consists in a subordinate and 
irregular imitation of the physiological glandular growth (heteradenie of the 



TU3I0RS OF THE MOUTH. 897 

inquisitive and learned histologists of the age. Clinically, it is to be 
affirmed that no surgeon lives who, upon the living subject, or upon 

French) has but a very contracted justification. After having above devoted 
so much time and space to the consideration of normal epithelial growth, it 
would ill become us should we now lose the fruits of that consideration by 
an ill-timed formation of hypotheses. For the carcinomas of glands with 
open outlets, of course we may even indicate with emphasis that all imagin- 
able transitions between glandular hypertrophy and the glandular carcinoma 
are to be found. We of the latest time have learned to know these interme- 
diate forms more fundamentally, and have invented the name adenoma, to 
designate a tumor which is neither simple hypertrophy nor carcinoma. This 
is at least the most comprehensive conception : several authors certainly 
move the idea of adenoma up # and down upon the scale mentioned, in that 
thej T now assign it more to hypertrophy, now more to carcinoma; that, how- 
ever, a motion up and down of this kind is possible, just proves the existence 
of the scale. 

" The general comprehension, however, of carcinomas, which proceed from 
the epidermis or the epithelium of mucous membranes, is much more diffi- 
cult ; namely, here also exists an unmistakable correlation of the hyperplastic 
and carcinomatous conditions. It is, for example, a well-known experience, 
that those circumscribed hypertrophies of the skin, which we term warts and 
papillomas, have the capacity of going over into epithelial carcinoma. This 
transition is brought about purely anatomically in the following manner : 
the papillar hypertrophy conditions a more or less great alteration of the level 
of that plane in which the epithelium and connective tissue come into con- 
tact. The steeply-raised lateral surfaces of the enlarged or newly-produced 
papillae bound deep, cleft-like- depressions between the papilla?. The epithe- 
lial covering of the papillae is at the same time an epithelial lining of the 
interpapillary clefts, and as long as this relation remains constant by a suffi- 
cient desquamation of the older epithelial cells, the hyperplastic character of 
the tumor is preserved. It is, however, manifest that a sufficing desquama- 
tion is so much the less possible, the more the papillae elongate, and especially 
the richer their dendritic ramification proves to be. The lateral pressure 
which the points of the papillae, widely branched but united to a narrow basis, 
exert, simultaneously closes from above the interpapillary clefts, and causes 
in them a gradually increasing accumulation of epithelial cells. The epithe- 
lium in the deeper parts of the tumor no longer appears as a lining, but as a 
solid plugging of the interpapillary clefts. As such it now begins to push 
forward against various points of the connective-tissue substratum. Oval 
epithelial cones appear, which first protrude from the under surface of the 
epidermis into the cutis, then penetrate deeper and deeper. By this the car- 
cinomatous condition is given. We cannot of course avoid comparing these 
cones with the epithelial cones in the glandular formation ; we also observe, 
as was said, lively processes of division in the constituent cells, although, 
until proof to the contrary has been shown, I am convinced that their growth 
chiefly depends upon a peripheric apposition of young cells, like the growth 

56 



898 ORAL DISEASES AND SURGERY. 

the dead one either, can mark a line of distinction at any exact point 
between a fibroma and a carcinoma : the author does not affirm that 

of normal epithelium, and find this representation just as plausible as per- 
haps the enlargement of retention-cysts by the secretion from their walls. The 
processes of division in the interior of the epithelial cones indicate a second- 
ary growth and may indeed contribute the greater part to the thickening of 
the epithelial cones ; to their elongation, however, and their forward progress, 
upon which the peculiar destruction of organs still depends, they do not con- 
tribute. In that I, in reference to the special elucidation of this matter, refer 
to the considerations following below of squamous epithelial cancers. I con- 
tent myself, in these preliminary remarks, to have pointed out that the laws 
of normal growth are correctly maintained even in these extremest and most 
dangerous excesses. ' ' — Kjndfleisch. 

11 In the neck, salivary ducts (closed internally and externally, but open in 
the middle, which are lined with epidermis) may, in the course of years, be- 
come large cholesteatomata by the deposit of epidermis. These show them- 
selves in the mouth (as ranula), or externally on the neck above and behind 
the thyroid. 

" In the mucous membranes, also, inspissation of the glandular mucus, and 
consequent hinderance to its evacuation, may cause development of mucous 
cysts ; but probably the more frequent cause of retention-cysts here is closure 
of the excretory duct. The secretion in these glands is usually a tenacious, 
often thick mucus, of a honey-color (meliceris), reddish yellow, or even 
chocolate-brown. On microscopical examination of the contents of the cyst, 
we find numerous large, pale, round cells, often containing fat globules, in 
homogeneous mucus, also cholesterine crystals, often in large quantities. In 
the nasal mucous membrane these cysts are rare, but they occur in nasal 
mucous polypi, often to such an extent as to give them the name of cystic 
polypi. Luschka often found small cysts in the mucous membrane of the 
antrum Highmori. In the oral mucous membrane they occur chiefly on the 
inside of the lips, more rarely on the cheeks : they are an ordinary occurrence 
in the uterine mucous membrane and in uterine polypi. In the rectal mucous 
membrane, on the contrary, mucous cysts do not occur, and they are very 
rare in the mucous membranes deep in the body. 

" While the above varieties of neoplastic cysts have no relation to gland 
new formations, those we are now about to mention develop from adenoma. 
The cysts of the thyroid, cystic goitre, have a somewhat uncertain position in 
this series ; uncertain because they are not due to newly-formed gland follicles 
or ducts, but to collection of mucous secretion in one of the thyroid vesicles. 
If we term the contents of these cysts secretion, as we might do for some reasons, 
we must class these cysts as retention-cysts. But, as it might be urged on the 
other hand that it would be questionable to speak of a secretion of the thyroid 
gland, as some state that normally the contents of the thyroid vesicles consist 
solely of cells, we may also consider the cysts resulting from softening of the 
contents of the vesicles as newly formed. Whichever view we take, it is 
certain that the cysts of the thyroid may be solitary, and may attain great 



TUMORS OF THE MOUTH. 899 

there is not such a line, but he does affirm that if there be, he has never 
been able to discover where it is. When meeting with a tumor without 

size. Moreover, in almost every large, and in some small, otherwise firm 
goitres, one or more cysts occur ; they usually have very smooth walls. The 
large, isolated cysts of this variety, particular^, give the impression that 
they are chiefly secretion-cysts, while other similar cavities in other parts of 
large goitres, by their softened, ragged walls, give the impression of being 
softening cysts. In the thyroid gland the process of softening usually ter- 
minates in the formation of a mucous fluid ; but there are other cysts in these 
glands that contain a gray, friable pulp, which looks like that from sebaceous 
glands, but differs essentially from it because it contains only the detritus of 
thyroid tissue ; I have never seen genuine atheroma pulp in thyroid cysts. 

" I must lastly mention cysts containing perfectly fluid venous blood, and 
having smooth walls, which are here and there mentioned in literature. 
Some of them refill rapidly, others more slowly, after puncture; such cysts 
have been observed in the axilla, on the thorax and neck. Excluding those 
cases where effusions of blood have given a dark-blood color to the mucous 
or serous contents of a cyst, and considering only those in which there is 
blood alone in the cysts, they could scarcely have been anything but large 
sacs on the veins or cavernous-venous tumors whose framework had been 
entirely atrophied. All the cases of this kind so far reported have been cured 
by puncture and injection with iodine, so that nothing can be said of the 
pathological anatomy. 

" The diagnosis of cystic tumor is easy; if it can be certainly palpated, the 
fluctuation will be felt ; deeply-seated cysts are often difficult to recognize. 
They may be mistaken for other encapsulated fluids ; an exploratory punc- 
ture with a very fine trocar is admissible to confirm the diagnosis, if this be 
necessary to determine the treatment. There are various things for which a 
cyst may be mistaken ; e.g. cold abscesses are also painless, occasionally very 
slowly enlarging, fluctuating tumors ; also cystic parasites, of which two 
varieties occur in the outer parts of the body, especially in the subcutaneous 
tissue ; cysticercus cellulosse and echinococcus hominis, although rare, do occur 
in the cellular tissue (and still more rarely in bone) ; the former is a small, 
the latter a large vesicle, which may contain many smaller ones ; the vesicle 
of which the animal consists always has a neoplastic sac around it; as may 
be readily seen, the whole thing gives the impression of a cystic tumor. I 
have seen cysticercus vesicles removed from the tongue and nose, echinococcus 
vesicles removed from the back and thigh. The diagnosis of cysts was made 
in all the cases except in one of the latter where abscess was diagnosed, 
and in fact, instead of the customary encapsulation, there was suppuration 
around the dead echinococcus vesicle. I have introduced this as a sort of ap- 
pendix, because we have nowhere else an opportunity of considering the para- 
sites. The millions of trichinae occasionally scattered through the muscles 
cannot be treated surgically, even when, according to the brilliant investiga- 
tions of Zenker, the diagnosis may be, and has been, made in many cases. 
Dropsies of the subcutaneous mucous bursas and of the tendinous sheaths, as 



900 ORAL DISEASES AND SURGERY. 

such local expression as described in connection with the first classi- 
fication, he knows of no rule of any service to the judgment. How 

well as spina bifida, may also be readily mistaken for cystic tumors, if we do 
not attend to the anatomical seat of these swellings. Cystomata may also be 
mistaken for other gelatinous soft sarcomata and carcinomata, and for very 
soft fatty tumors. As stated, when an intention of operating renders a cer- 
tain diagnosis necessary, we make an exploratory puncture. But what guides 
us chiefly, in the diagnosis, is the experience about the relative frequence of 
different tumors on different parts of the body ; I have given you the sum of 
these experiences in each form of cyst, and in the clinic shall hereafter direct 
your special attention to this point. 

' ' As the above includes the prognosis of cystic tumors, all of which grow 
slowly when they exist as cysts without complication, we may pass at once to 
their treatment. "We may remove cysts in two ways, viz. : by evacuating the 
contents, and locally applying remedies that may excite an inflammation 
which shall cause atrophy of the sac, or by extirpating the sac ; the latter is 
always the simplest and most rapid, and we always give it the preference 
where it can be done easily and without danger to life. But in cysts of the 
ovary, thyroid, and other glands, that are deeply seated or from other causes 
dangerous, some other, safer operation is of course desirable, if it offers a pros- 
pect of success. "We may induce shrinkage of the sac after precedent evacu- 
ation of the contents, by a suppurative or by a milder, drier inflammation. 
If you slit up the wall of the cyst its whole length, and keep the cut edges 
apart, there will be suppuration and granulation of the exposed inner wall of 
the cyst, with detachment of the portions of tumor or epithelium clinging to 
it; the sac then gradually shrinks up into a cicatrix, then decreases in size, 
and finally heals ; but this may require months. You may attain the same 
thing in a more subcutaneous way, by ligatures or tubes through the tumor 
at different points ; the irritation caused by these, as well as by the entrance 
of air, causes suppuration and granulation of the inner wall, and in favor- 
able cases these may lead to atrophy ; often this does not occur in the manner 
desired, or else it may require months or years ; so that of these two methods 
the first is preferable ; it is particularly applicable to cysts of the neck. ~We 
may attain shrinkage of the cyst and drying up of its contents in another 
way, namely, by puncture, with subsequent injection of tincture of iodine ; 
we have already said enough about the effect of this treatment. Here, 
too, the injection is followed by severe inflammation of the sac with sero- 
fibrinous exudation ; then the serum is reabsorbed and the sac contracts. The 
latter method is particularly applicable when we have to deal not with con- 
tents of softened tissue, but with a fluid secreted by the walls of the sac, that 
is, chiefly with cysts whose contents are serous, and some sorts of mucous 
cysts. Cystomata developed from softened gelatinous substance and fat-cysts 
are not suited for iodine injections ; for they are apt to be followed by severe 
inflammation and suppuration, with formation of gas, so that we are subse- 
quently obliged to slit up the entire sac. And very thick walls, which contract 
very slowly or not at all, also contra-indicate iodine injections. Hence among 



TUMORS OF THE MOUTH. 901 

harmless or how malignant a non-explainable tumor is to prove 
can only be judged by an experience that has seen much of such prac- 

cysts'of the neck we find some that are suited for this treatment, others which 
are not, because their walls are too thick. Of the ovarian cysts, too, unfortu- 
nately but few are suited for treatment by iodine injection, so that recently 
the extirpation of these tumors by laparotomy is considered the only certain 
operative proceeding ; of late years the results from this operation have con- 
stantly been growing more favorable. Lastly, we must state that in some 
cases it is best to avoid any operation ; for instance, I should consider it folly 
to persuade an old man, with a number of atheromata on his head, to have 
them removed ; for, if the operation were followed by erysipelas, it might 
prove fatal. 

" The common clinical definition of carcinoma should be controlled by the 
anatomical structure of these tumors. Anatomical peculiarities, easily recog- 
nized with the naked eye or with the microscope, are sought for. The classi- 
cal monographs of Astley Cooper on diseases of the testis and breast (the latter, 
unfortunately, unfinished) show that by a careful study of the points percep- 
tible to the naked eye, a great deal may be attained by studying a single 
organ ; but a generalization by aid of the anatomical preparations alone is 
impossible, as we have often felt, in the course of these lectures — it is fre- 
quently difficult, even with our present aids ; so that I cannot blame Virchow 
for trying, in his great work on tumors, to give most minute descriptions of 
the different forms of tumors at certain localities. Here, where we must ex- 
press ourselves briefly, to give our descriptions an anatomical basis, we must 
be somewhat more decided and summary. When the naked eye no longer 
sutficed for the diagnosis of tumors, the aid of the microscope was invoked, 
and characteristic appearances were sought that might occur in the same way 
in all the tumors we have described. Still, whether the characteristics of the 
cellular elements were sought in their processes, the size of the nucleus or of 
the nucleolus, the clinical and anatomical peculiarities would not always re- 
main congruous. When the cells proved inefficacious as evidence of carci- 
noma, it was sought for in the general structure of the tumor; alveolar 
formation was asserted to be the anatomical peculiarity. We even come in 
collision with this idea occasionally ; the net-like formation of neoplastic 
lymphatic gland-tissue may also be termed l alveolar,' and even acknowledg- 
ing that the lymphoma net-work is so peculiarly characterized by its form 
that it may be readily excluded, there still remain some forms of chondro- 
mata and sarcomata, especially the giant-celled and other large-celled sar- 
comata forms, which we have already designated as alveolar sarcomata, as 
the ghosts of cancer. 

" The more I feel obliged to suppose that in the perfect organism there are 
no entirely indifferent cells, but that the elements of the middle germ-layer 
of the embryo and of the two epithelial layers are always somewhat in oppo- 
sition, the more I am inclined to use this fundamental histogenetic fact for 
the development and division of tumors. In accordance with this, I only 
call those tumors true carcinomata which have a formation similar to that of 



902 ORAL DISEASES AND SURGERY. 

tice. If this is lack of wisdom, then is it a necessity to admit that 
there is no malignant dyscrasia, but that local differences of disease 
depend strictly upon local causes. 

true epithelial glands (not the tymphatic glands), and whose cells are mostly 
actual derivatives from true epithelium. I am convinced that this view will 
constantly have more adherents, and that thus the difference about the ana- 
tomical definition of ' carcinoma' will constantly diminish. Those investi- 
gators who, during the last few years, with all the modern aids, have worked 
without prejudice on this portion of the study of tumors, recognize the great 
importance of epithelial proliferation in those tumors that we call cancer ; 
still, most of them seek for a compromise between the different histogenetic 
views, and wish still to admit, in a modified form, the development of true 
glandular and epithelial cells from connective tissue (heterology proper) (Rind- 
Jieisch, Volkmann, Klebs, LucJce) ; only Thiersch, and recently Waldeyer, main- 
tain, as I do, the strict boundary between epithelial and connective-tissue 
cells. Waldeyer defines carcinoma as an atypical epithelial neoplasm. But 
we must here state that in cancer-tumors, besides the epitheliums, there are 
usually numerous young, small round cells which, infiltrated in the connective- 
tissue portion of the tumor, form an important part of it. This small-celled 
connective-tissue infiltration, which exists in varying quantities wherever 
epithelial proliferations grow into the tissue, appears to be caused by a sort 
of reaction, and to be the result of the penetration of the epithelial new for- 
mations into the tissue, according to the number of infiltrated cells and their 
future fate, as well as the degree of vascularity, just as in inflammation it 
sometimes leads to softening, to atrophy, and cicatricial thickening of the 
tissue. In some cases this small-celled infiltration is so considerable as almost 
entirely to hide the epithelial new formation (from which it may be very diffi- 
cult to distinguish, if the latter be small). We may then be in doubt if it 
should not be regarded as entirely independent, and occasional^, perhaps, as 
the sole constituent of cancerous tumors. Formerly I myself thought it 
necessary to agree to this, and even supposed that this component of carcinoma 
possessed a spontaneous power of infection ; but further observations with 
new aids have made it appear to me more probable that, even in the smallest 
cancerous nodules, epithelial elements always gave the first start for develop- 
ment. This has been confirmed by V/aldeyer. 

11 It is especially important to make a distinction between adenoma and car- 
cinoma, as the two forms of tumors have some points in common. Pure ade- 
nomata are composed of newly-formed gland-substance which is entirely 
analogous to or at least very much like the normal ; the connective tissue 
around the newly-formed acini has the same relation to them as to the normal. 

" In adeno-sarcoma there is little if any new formation of glandular acini, 
but the sarcoma merely incloses the glandular spaces which have remained 
normal, or are dilated. But it is characteristic of carcinoma that the epithe- 
lial covering of a skin or mucous membrane, or the epithelial lining of glan- 
dular cavities, grows into the skin, and even deeper, in the form of roundish 



TUMORS OF THE MOUTH. 903 

Carcinoma, as the jaws are concerned, may be studied under the 
expressions of histoid mixed tumors, scirrhus, sarcomatous sar- 

nodules (acinous), or of round cylinders or rollers (tubular), just as occurs in 
the foetus. "While so doing, the epithelial cells usually preserve their form, 
only they often grow much larger than normal. The form of the glands 
from which these formations proceed generally remains typical for the neo- 
plasm also ; but it remains in irregular forms of glands ; it is only rarely that 
cavities are formed, and that actual secretion goes on in these cavities. Be- 
sides the epithelial parts of these tumors, the connective tissue, bones, muscles, 
etc., into which the epithelium enters, conduct themselves as follows: "We 
sometimes find them of. normal, again^if abnormal firmness, sometimes very 
soft, almost mucous, ordinarily in less quantity than the epithelial masses. It 
is usually pervaded by small, round (lymph) cells, often to such an extent that 
scarcely any fibrous tissue is left ; generally the infiltrated small cellular ele- 
ments are scattered diffusely in the cancerous (connective-tissue) framework ; 
very rarely we find numerous cells, collected together in a fissure between 
the connective-tissue bundles. When the tumor advances into the bone, the 
latter is eaten away, as in caries. I have not been able to satisfy myself that 
there is any new formation of connective-tissue filaments in the nodular and 
infiltrated forms of these tumors, nor have I been able to find any osseous 
new formation ; but there is no doubt that such a new formation occurs in the 
papillary and villous forms, of which we shall hereafter speak. From this 
description you see that Waldeyer' s expression about the epithelial formation 
in carcinoma being atypical (tissu heteroadenique of Robin) is also well suited 
for distinguishing carcinomata from adenomata, as typical new formations. 

" As regards the vessels in these tumors, we may satisfy ourselves, by artifi- 
cial injections, that the dilatation and new formation, by tortuosity and loop- 
ing, are considerable; only the connective-tissue portions of the tumor are 
vascularized, the epithelial portions remain free. I cannot go any further 
into the general histological description of these tumors, and hope that they 
may be recognizable from the above, although I acknowledge that it is 
sometimes very difficult to distinguish carcinoma from adeno-sarcoma and 
alveolar sarcoma. 

" According to my whole histogenetic view, I must regard it as impossible 
for an epithelial cancer to occur primarily in a bone Or lymphatic gland. The 
observations that I know, to this effect (in the lower jaw, on the anterior 
surface of the tibia, in the lymphatic glands of the neck), do not seem to me 
sufficient proof, because the skin and mucous membrane are so near ; there 
may have been an insignificant carcinomatous disease of the skin or mucous 
membrane as a starting-point of the disease, without its having been noticed. 

" The appearance of the cut surface of this tumor, and its consistence, vary 
so, that no general description can be given of it. 

" In the great majority of cases, carcinoma appears in the form of nodules ; 
also as indurations of otherwise soft tissues, or as papillary proliferations. 
Rarely, the diseased parts are separated from the healthy tissue by a connective- 
tissue capsule ; but, in most cases, the passage from healthy to diseased tissue 



904 ORAL DISEASES AND SURGEBY. 

coma, the telangiectatic and encephaloma: these, as understood, 
are merely arbitrary divisions, and might, with all histological pro- 
priety, be enlarged to include the many other expressions belonging 
to the class. (Refer to works on Pathological Histology). 

Histoid Mixed Tumors.* — The tumors described as fibromata, 



is more gradual. In some eases there is no cancerous tumor, but a cancerous 
infiltration, there being no enlargement, possibly even a diminution in size 
of the affected organ. It is also characteristic of carcinoma that part of the 
new formation is very short-lived, disintegrates directly or after precedent 
fatty degeneration, is reabsorbed, and then the infiltrated fibrous tissue con- 
tracts to a firm cicatrix. Besides this cicatricial shrinking, and not unfre- 
quently along with it, there is often softening ; it is, perhaps, even more 
frequent than contraction ; at all events, it is more extensive. This soften- 
ing is mostly preceded by fatty degeneration of the cells and caseous meta- 
morphosis; central softening, opening outwardly, formation of a putrid ulcer, 
with fungous edges, is very characteristic of carcinoma. Mucous metamor- 
phosis of the cell-protoplasm also takes place in some glandular carcinomata, 
relatively most often in those of the liver, stomach, and rectum; in rare 
cases, this also affects the connective-tissue stroma. This mucous cancer is 
also called gelatinous or colloid. "When cancerous degenerations occur on the 
surface, the papillary layer may develop so as to become very prominent, as 
in some papillary cancers (destructive papillomata) of the mucous membrane 
of the lips, stomach, and portio vaginalis, and as in villous cancer, which de- 
velops on the mucous membrane of the bladder, in the form of dendritic, 
branched, large papillse. If the cicatricial contraction predominate in a car- 
cinoma (as it does in some forms of cancer of the breast), hard tumors or ulcers 
are developed, which have for ages been called scirrhus. Some carcinomata 
are brown or black, but still melano-carcinomata are rare. Most soft melano- 
mata are sarcomata. You will more readily acquire an idea of the different 
forms of cancer by studying attentively their origin and the localities where 
they chiefly occur."— Billroth. 

* " Histoid Tumors. — In the capability of the intermediary nutritive appa- 
ratus, of producing embryonal connective tissue at almost every point of the 
body, those higher histogenetic actions are also founded, which we in the 
more contracted meaning of the word term excrescences, more correctly, 
however, histoid tumors. The interior continuity of their elementary parts 
is characteristic of histoid tumors. The majority of them consist generally 
only of one tissue ; where, however, more tissues participate in the compo- 
sition, they are never found in a differential apposition determined by sharp 
limits as epithelium and connective tissue, but they organically pass into 
each other. This intimate continuity is declared also from the original interior 
uniformity of the foundation of the tumor, which in all cases is given by a 
certain amount of embryonal formative tissue. From this only by subsequent 
differentiation do the higher types of tissues proceed, and, indeed, with a pe- 
culiar predilection the connective substances, the connective tissue itself with 



TUMORS OF THE MOUTH. 905 

sarcomata, etc. possess their appellation from a distinctiveness of 
tissue which characterizes them in their purest expression. In the 
histoid mixed, two or more elements are found conjoined, thus, as is 
seen, confusing necessarily classification by such distinctions. When, 
as has been queried by Rindfleisch, besides distinct lipomatous con- 
stituents, distinct chondromatous features are found ; when sarcoma 
nodes and nodules are deposited in an enchondroma, we do not know 
whether we should name this thing enchondroma lipomatodes, or 
lipoma cartilagineum, or sarcoma cartilagineum, or chondroma sar- 
comatosum. This embarrassment recurs with the question as to the 
clinical character of this sort of tumor, the prognosis, etc. The his- 
toid mixed tumors, as has been shown, will, in the mouth, be found 
more common than the pure histoid ; their nature and character, from 
what has preceded, will be appreciated. 

Scirrhus. — Although the very rarest of the expressions of the 
cancer vice as met with in the mouth, yet as a form of the dyscrasia 
clinical attention will occasionally be directed to the condition. 
Scirrhus is a condition of adult life, rarely appearing before the age 
of forty, and even then seeming, in its isolation, a something concen- 
trating itself for purposes of operative relief. Commencing in the 
gum or alveoli, and secondarily affecting the bone, scirrhus ap- 
pears as a small nodule, incompressible, having indeed a lead-like 
feel. What now is to be its progress depends pre-eminently on cir- 
cumstances. The author has at the present time under charge a 

its varieties (fibroma and sarcoma) occurring in the inflammatory process, the 
cartilaginous tissue (chondroma), the osseous tissue (osteoma), the adipose 
tissue (lipoma), the mucoid tissue (myxoma), the higher anomalous tissues, 
the muscular tissue (myoma), and the nervous tissue (genuine neuroma) are 
more rarely produced. The manner of the production, again, is exactly the 
same as in foetal development ; that is to say, a certain amount of embryonal 
formative cells are converted into cartilage, bone, fat, and muscle-cells, while 
the remainder is converted into connective tissue, and beyond this the whole 
is divided by a sufficient vascularization into nutritive territories of the entire 
organism. Herewith upon the one hand the connection of the tissues among 
themselves is preserved, upon the other these with the organism ; the new 
formation appears as an organ, although defectively built and unnecessary. 
Without the integrity of the body being attacked, colossal new formations 
often arise, which need only to be removed by the knife, in order to re-estab- 
lish the previous status. 

" What I last said, of course, does not, however, obtain without restriction. 
Unfortunately, there are also among the histoid tumors a number to which 
we must ascribe a pernicious character, malignitas." — Eindfleisch. 



906 ORAL DISEASES AND SURGERY. 

scirrhous tumor associated with the periosteum immediately beneath 
the left malar bone, which made its appearance in 1859 : this tumor 
grows neither larger nor smaller, being held in abeyance either by the 
lightness of the dyscrasia or — what amounts to precisely the same 
thing — the resistive powers of the antagonizing life-forces. A second 
case is a lady, still under care, from whose under lip, two years back, 
was removed a tumor yieldingthe microscopic expression of scirrhous 
carcinoma, and with whom there has been no return of the disease. 

Asa scirrhus advances in its development, there becomes asso- 
ciated with it a lancinating character of pain particularly diag- 
nostic, the presence of which is commonly admitted to decide any 
existing doubt. Still advancing, the overlying structures become 
implicated, the skin contracts and adheres, and soon shows an 
increased vascularity ; later in its progress the tumor puts on the 
character of a pointing abscess, or ulcerates with a lupoid expres- 
sion, or cracks ; finally the telangiectatic expression is assumed, 
exuberant granulations springing forth, giving to the patient the 
disgusting associations of the fungus hgematodes, and soon wearing 
out the life-forces. 

The diffusion of scirrhus should be one of the most interesting, 
as it is certainly one of the most important, matters of surgery. At 
first appearing as a solitary nodule, the tendency in the condition to 
multiply its expressions is a sufficiently recognized fact. The author 
has been, of course, understood as indorsing the humoral theory, 
believing in a preliminary dyscrasia of which a tumor is simply the 
expression ; but there is the other side to the question, and nowhere 
better than just here may its arguments be introduced.* (See 

* "Let us now go more minutely into the etiology of tumors. Here we 
should propose to find the differences and points of resemblance between the 
processes causing inflammatory neoplasia and tumors. Let us start with the 
causes of inflammation, and compare them with those of tumors. Many 
acute inflammatory processes (exanthemata, typhus, etc.), and some chronic 
ones (intermittents, scorbutus, etc.), are due to miasmata and contagions, 
which enter the body from without. I do not know any acute miasmatic tumors ; 
but goitre must be considered as a chronic endemic miasmatic tumor ; goitre 
cannot he regarded as a product of inflammation, as it never spontaneously 
retrogrades, suppurates, or shrinks up into a cicatrix ; the cause is a specific 
external one, to which every one, especially the young, is occasionally ex- 
posed, who comes into a country where goitre is endemic ; all are not equally 
disposed to it, there may he an hereditary tendency ; infection probably 
occurs through the blood ; at least, we cannot well imagine how the thyroid 




TUMORS OF THE MOUTH. 907 

foot-note ; see also " Cellular Pathology," by Virchow, pages 90 to 
100, and 252 to 254; also, Essay .of Mr. Moore, "Holmes's System 
of Surgery." 

After the removal of a single scirrhous nodule, the recurrence, if 
it takes place, is apt to be in the form of numerous secondary papules, 
or else with a medullary ex- 
pression. Fig. 216 exhibits 
almost photographically this 
disease as it made its reap- 
pearance in the mamma of a 
lady from whose axilla the 
author had removed a scir- 
rhous gland. In its medul- 
lary expression the disease 
may occur in the site of re- 
moval, but it is more prone 
to reappear in the viscera. 
When occurring in a viscus, 
the cachexia is quickly made 
evident, the countenance be- A view of the numerous nodulated tumors which 

often form in the cicatrix after the extirpation of the 
COming leaden in hue, the former growth. One is represented as ulcerated in 
features pinched, and the lips the site of the mammilla. (After Miller.) 

livid. (See Paget, on the Cancerous Diathesis.) 

Concerning duration, scirrhus is apt to complete its history in 

gland should be infected by local infection. Hence goitre is probably the 
local expression of a general infection, which occasionally evinces itself in 
the whole nutritive state, especially in anomalous development of the skeleton 
and its results (cretinism). "We may also consider leontiasis and Oriental 
elephantiasis as chronic miasmatic infections, in which large masses of nodu- 
lar fibrous tumors form in the skin on different parts of the body. Still, I 
acknowledge that this is disputed territory, and that reasons may be advanced 
for classing these among the chronic inflammatory diseases, instead of among 
tumors. As regards local infection, or the transfer of fixed contagions from 
without, we know that inflammations of various kinds may be thus induced. 
By putrid substances. only inflammations are induced; here I class, also, the 
so-called 'dissecting tubercle,' which I cannot consider as a tumor, because 
it disappears spontaneously, as soon as new infection ceases to occur. Inflam- 
mation is excited by inoculation with pus ; the character of the pus determines 
the specific nature of the inflammation ; pus may also excite a constitutional 
disease, which again may evince itself by multiple localized processes, as in 
syphilis. Can tumors be induced by inoculation with the juices of tumors, 
or with small portions of them ? This is a disputed point ; I consider it pos- 



908 ORAL DISEASES AND SURGERY. 

from two to three years, although, as has been remarked, cases may 
remain in abeyance for many years. 

sible, but not proved; the difficulty of coming to a decision lies in the fact 
that it is not allowable to make such experiments on men. When such 
experiments often fail on the lower animals, it only shows that tumors from 
man are not transferable to them ; tumors from beasts must be inoculated on 
beasts of like species ; a few such experiments have been made by Doutrele- 
po?it, in which the inoculations of carcinoma from dogs on dogs had no effect. 
At all events, we cannot induce a tumor by inoculating with pus, which again 
seems to show the specific difference of the products. Perhaps some patholo- 
gists may here answer that ' molluscum contagiosum' is an example of tumor- 
juice or constituents of tumors being inoculable on other persons. This fact, 
which has been proved by Ebert and Virchow, is very interesting ; still, the 
right of molluscum contagiosum, a cystoid secretion-hyperplasia of the seba- 
ceous glands, a sort of large comedones, as well as that of retention-cysts 
generally, to a position among tumors is disputed ; and, moreover, the con- 
tagiousness of this neoplasia is still too isolated for us to draw any valuable 
conclusions from it. The most striking proof of the distinctness of inflam- 
matory products and tumors is offered by observation of the local and general 
infection, which we have innumerable opportunities of making. We have 
previously said a good deal about progressive and secondary inflammation of 
acute lymphangitis, which is always secondary (deuteropathic,. Virchow), of 
the secondary acute and chronic swellings of the lymphatic glands in acute 
and chronic inflammations, especially of the extremities ; I then told you that 
I considered it more probable that cellular elements from the focus of inflam- 
mation passed into the lymphatic glands, and, by their specific phlogogenous 
action, induced inflammation in the glands, which were analogous to the 
primary peripheral inflammations ; tumors never develop through such local 
infections from inflammatory foci ; if the primary inflammatory focus be 
removed, the swellings of the lymphatic glands also disappear. Similar 
infectious peculiarities also occur in many tumors, especially those which, 
like the inflammatory neoplasia, are very rich in cells ; not only may the 
immediate vicinity be infected, and numerous new foci be formed immedi- 
ately around the first nodule, but very often the lymphatic glands are also 
affected, and secondary tumors form in them, which have the same peculiari- 
ties as the primary ; nor are they any more apt to disappear spontaneously 
than the primary, even when the latter is removed; on the contrary, similar 
tumors then frequently appear in other quite remote parts of the body — 
metastatic tumors. Here you again have the analogy with the course of 
infection in inflammation, as well as the specific distinction, for metastatic 
growths never result from phlogistic infection, any more than metastatic 
abscesses in internal organs do from infection by a tumor. Infection is not 
common to all tumors, although, unfortunately, the majority are infectious ; 
these are called malignant, in contradistinction to the benign, or non-infec- 
tious. It is difficult to say on what this difference is based ; it is probably 
partly due to the nature and specific character of the element, in their easy 



TUMORS OF THE MOUTH. 909 

Section of an amputated malignant scirrhus shows a concave sur- 
face, deemed to be very diagnostic of malignancy; it is smooth, being 

mobility, and in the fact that, like the seed of some of- the lower plants, they 
find almost everywhere soil suited for their development, and can grow in 
most tissues of the body : probably it is also partly clue to the fact that the 
conditions are more or less favorable to the entrance of the elements of the 
tumor into the lymph or blood-vessels ; for instance, it is remarkable that 
frequently very soft tumors (medullary sarcoma) consisting almost entirely 
of cells, when surrounded by a firm connective-tissue capsule, cause no infec- 
tion of the lymphatic glands ; we notice the same thing in some large encap- 
sulated abscesses. In regard to metastatic abscesses, I have already told you 
that, according to my view, they are due to embolism ; we should have to 
seek another explanation of diffuse metastatic inflammations. Diffuse metas- 
tatic tumors are very rare ; I should apply this term only to a few forms of 
pleural and peritoneal carcinoma or sarcoma. As regards the mode of origin 
of metastatic tumors, the actual course of the infection, from analogy, it 
seems very probable that they, like the secondary tumors of the lymphatic 
glands, are induced by seed from the primary tumors, or from the tumors in 
the lymphatic glands. I acknowledge I am much inclined to this supposition. 
Although I could not formerly believe that the cells from a focus of inflam- 
mation or from a tumor could be as independent as thistle-down, still, I think 
that, with our present knowledge about the independent life of pathologically- 
neoplastic cells, there can be no doubt of the possibility of such a process. 
Although, on the first development of a tumor, as on the occurrence of an 
inflammatory new formation, the lymphatic vessels are partly closed, and 
may be filled with cells, still, subsequently, from compression, lymphatic and 
vascular thrombi may form, into which specific tumor-elements enter, and 
small particles of thrombi, which might form during the softening of the 
tumor, may enter the circulation, become attached at different places, and 
form new tumors. In veins, the formation of such thrombi filled with specific 
tumor-elements has actually been observed, and, at the same time, analogous 
tumors have been found in the branches of the pulmonary artery. It is 
important to remember that metastatic tumors, like metastatic abscesses, are 
chiefly found in the lungs and liver, except in cases where direct metastasis 
is very easy, as in pleural tumors, which develop as a result of primary mam- 
mary tumors, as in hepatic tumors found with those of the intestines or 
stomach ; in these cases a direct wandering of tissue-elements through the 
lymphatic vessels is very possible. On this point there is still much room for 
investigation, which, I think, will meet great results. As we have already 
seen, the products of acute inflammation mostly have a pyrogenous action ; 
those of chronic inflammation lack this peculiarity almost as much as do 
those of tumors ; fever only occurs in the latter when there is disintegration 
of the neoplasia, and the products of the disintegration enter the circulation ; 
more frequently, infection with such excreted matters shows itself in chronic 
inflammation in tumors by a general cachectic state, especially by disturbance 
of the general nutrition. 



910 



ORAL DISEASES AND SURGERY. 



indeed very similar to the section of a fresh turnip. Scraping the 
surface affords what is commonly called the cancer-juice, the micro- 
scopic cell features of which are exhibited in Fig. 277. 

Fig. 277. 




A microscopic view of the cells of hard cancer, showing their varied shapes, with the 
numerous free nuclei, as seen in scirrhus of the breast. Magnified 500 diameters. 
(After Paget.) 

It will be seen from the great variety of feature exhibited in these 
cells that there is here no characteristic cancer-cell. The judg- 
ment of such growths is to be founded on the common heteroclitic 
expression. 



" If we consider what has been said about the contagiousness of tumors, 
we see that there is some probability of their transfer from one person to 
another, though it is not proved ; but there can be no doubt that the lymphatic 
glands and other organs may be gradually infected by various kinds of tumors. 

"As regards the effect of taking cold locally and generally as a cause of 
inflammation, there are no observations which would justify us in referring 
tumors to a similar cause. I do not know that any one has ever asserted and 
proved that tumors result from catching cold. 

" Views vary greatly about mechanical and chemical influences as causes of 
tumors. Various as the irritations may be, and much as they have been 
experimented with, in no single case has a tumor been caused intentionally 
by mechanical or chemical irritation ; inflammatory new formations thus 
developed do not long outlast the external irritation. Wherever and how- 
ever we apply such mechanical and chemical irritants, we only induce inflam- 
mations ; if there be any specific mechanical and chemical irritation (I mean 
one acting on the organism from without, not starting from the tumor), i.e. 
one from whose action a tumor must develop, it is at present unknown. Then 
the question arises whether there are any reasons which render it absolutely 
necessary to assume such mechanical and chemical irritation outside of the 
organism. I cannot agree to this. It is true there are many cases where a 
tumor forms after a blow, kick, or injury, but the number of such cases is 
very small in proportion to those where, after similar causes, there is acute 
traumatic inflammation, with a typical course, or, if the irritation be con- 
tinued, chronic inflammation also with typical course. "We must regard this 
also as a rule : if a porter gets a thickening of the skin, with new mucous 
bursa under it, on the spinous process, or if he gets an ulcer at the same 
point, it is to some extent a normal result, they are products of a chronic 



TUMOBS OF THE MOUTH. 911 

The Sarcomatous Carcinoma. — This expression, from the his- 
tological stand-point, is to be described as a tumor exhibiting the 

inflammatory irritation, and disappear as soon as the irritation ceases ; but if 
from the same causes a person gets a fatty tumor, which does not disappear, 
but even continues to grow when the irritation ceases, we cannot here regard 
the irritation as specific, hut must seek the peculiarity in the affected part. 
Previously in general and local infections we recognized the specific effects of 
irritation ; now we must also acknowledge that there is a specific, qualitative, 
abnormal reaction of the tissue. Virchoio and 0. Weber especially have 
maintained that external irritation always plays an important role in the 
development of tumors ; this follows undoubtedly from the fact that primary 
tumors are most frequent at points most subject to external irritation. Sta- 
tistics show that the most frequent seat of tumors is the stomach, then the 
portio vaginalis uteri, then the face and lips, then the mammary glands, rectum, 
etc. But the reason for the development of tumors, and not of chronic inflam- 
mation in such cases, must be a specific disposition of these parts in certain 
persons. Individuals who drink much spirits usually have gastric catarrh ; 
if, among one thousand topers, one or even ten, instead of catarrh, had cancer 
of the stomach, he should be considered as an abnormal subject, when com- 
pared with the mass who do not have it. Up to this point I agree entirely 
with Virchow, who speaks as follows : 'Although I cannot tell in what par- 
ticular way an irritation must occur, to induce a tumor in some given case, 
while in another case, perhaps under apparently similar circumstances, it 
merely excites simple inflammation, still I have communicated a series of 
facts which teach that, in the anatomical composition of different parts, certain 
continuous disturbances may exist which interfere with the occurrence of 
regulating processes, and which, from an irritation that at another spot would 
have induced a simple inflammation, excite an irritation from which the 
specific tumor is developed.' Among facts 'which teach that, in the anatomical 
composition of different parts, certain continuous disturbances may exist' 
which dispose to development of tumors, Virchow mentions advanced age. It 
is perfectly true that certain forms of tumors are very frequently found on 
particular parts of the body in old persons, e.g. cancer of the lip. Thiersch 
calls attention to the fact that in the lips of old men the connective tissue is 
often so much atrophied that the epithelial tissues (sebaceous, sweat, and 
mucous glands, hair-follicles, etc.) become very prominent, and, as it were, 
receive the preponderance of nutrition ; that hence irritation shows itself 
chiefly in the proliferation of these epithelial formations, and that this ex- 
plains the frequent occurrence of epithelial cancer in the lips of old men. I 
fully recognize the shrewd combination of these observations, but I must add 
that advanced age is just as much a general as a local peculiarity of the body. 
It is also stated by Virchow that places which have been the seat of an inflam- 
matory disease, which has left the part weakened, also cicatrices, furnish foci 
for the development of tumors. This is undoubtedly true ; but if we com- 
pare the innumerable cases where simple chronic inflammation occurs in 
parts that have been acutely diseased, and where simple ulceration occurs in 



ill 



912 ORAL DISEASES AND SURGERY. 

features of sarcoma and carcinoma in combination. Such combina- 
tion may reside in degeneration of the sarcoma, or may arise from a 

cicatrices, the cases in which tumors occur at such points appear very small, 
and it must be acknowledged that in these few cases we may assume a specific 
predisposition which leads to formation of tumors. The same holds good for 
the fact that tumors are particularly apt to form in organs which complete 
their formation and development late in life ; here Virchow classes the articu- 
lar ends of the bone (which, however, are the seat of tumors much more 
rarely than of chronic inflammations), the mammary glands, the uterus, 
ovaries, testicles, etc. "While fully recognizing the exercise of observation 
and brilliant ideas by which it is attempted to prove the purely local disposi- 
tion to development of tumors, I cannot consider the proof as at all con- 
vincing, but remain of the opinion that there is just as much a specific predis- 
position to the development of tumors as there is to chronic inflammations, toith 
proliferation of the inflammatory new formation, with suppuration, with caseous 
degeneration, etc. 

" To what has just been said we must add that we cannot always detect a 
local external irritation when a tumor is developed, any more than we can 
always do so in local disease in a scrofulous patient. While referring you to 
what has been said on the etiology of chronic inflammations, I would remark 
that in regard to primary tumors we may assume in many cases that there 
are also specific, so-called internal irritations developing in the body itself. 
Most pathologists agree to this, but they consider the mode of origin and 
development of such irritations as being different. Virchow teaches that the 
local disease must have a local cause, and assumes that at the point of disease 
there are certain local conditions of debility. If this were so, we should 
have to assume a specific local debility for the most different disturbances of 
nutrition and for formation of tumors. Rindfleisch speaks very decidedly of 
internal irritation as follows : ' By the change of substance in the tissues, 
certain excretive substances are constantly being formed, which must gradu- 
ally be passed off from the tissues and organs in which they form, as well as 
from the fluids of the body at large, in order that the life of the individual 
may be undisturbed. These bodies have their chemical position between the 
organopoietic bodies on the one hand and the excreted matter of the kidneys, 
skin, and lungs, on the other; thus they fall into the great gap that exists in 
organic chemistry at this point ; they are different for the different tissues, 
and on this difference depends the variety of pathological new formations. 
If they are transformed and excreted normally, they collect first at the point 
of their origin, then in the fluids of the body, and this collection is the im- 
mediate cause for the excitement of that progressive process which begins 
with multiplication of cells in the connective tissue and ends with the de- 
velopment of tubercles, cancer, cancroid, fibroids, lipomata, etc' I can 
entirely agree with this hypothesis, but must add that it seems an error to 
suppose that we here speak chiefly of local processes. The production of bile 
and urine is also a local process ; for them to be produced in such quantities 
and of such a quality as they are depends not only on the glandular organs, 



TUMORS OF THE MOUTH. 913 

primary combination : this is explainable by imagining the inter- 
stitial connective tissues to undergo sarcomatous degeneration, 

but on the entire organism to such an extent that we must seek the original 
causes of the secretion of urine and bile not only in the blood, but even more 
remotely, even in peculiarities of origin, as far back as Adam, if you please. 
In the same way, I think that the original causes for the local requirements 
for the development of tumors must be sought in specific peculiarities of the 
individual organism ; in the same way we speak of a scrofulous or tuberculous 
person, meaning the pathological race, as it were, to which the individual 
belongs. 

" I must lastly add that the supposition that the cause of disease, the irrita- 
tion inducing the tumor, develops locally, where the tumor afterward forms, 
is as purely hypothetical as any that has yet been advanced. Let us take 
arthritis as an analogy: Zaleski induced the most typical arthritis in a goose 
by ligating the ureters, an articular disease resulting from disturbance of 
the function of the kidneys. Possibly tumors might just as well develop in 
any tissue from disturbance of the hepatic function. Very many things are 
possible. "We know nothing certain on this point, and move entirely in 
hypotheses. For my part, I find it just as allowable to assume a diathesis 
here, as in scrofula, arthritis, etc. ; that, partly from unknown, partly from 
known causes of general nutrition and ordinary conditions of life, abnormal 
matters proceed, Avhich have a specific irritant action on this or that part of 
the body, analogous to that of certain drugs. Lastly, if to this we add that 
the diathesis for production of tumor is hereditary, although not to such an 
extent as the chronic inflammatory diathesis, the doctrine of weakness local- 
ized in certain systems of tissue or certain parts of the body seems entirely 
untenable. There is certainly a local cause for the members of one family 
having large noses ; in proportion to the face, they have grown larger than 
in other men ; still, the large nose of the father cannot descend directly to the 
son, it can only he inherited from the father through the spermatozoa, and 
there the original cause is to be sought; all peculiarities that descend by 
inheritance are unquestionably to be termed constitutional. 

" I have now occupied you some time with reflections which some of you 
may consider very tedious ; they will ask me, Of what use are these things in 
practice ? Then, unfortunately, I must acknowledge that practice pays little 
attention to them, because they are so hypothetical. Those of you to whom 
such ideas as we have just spoken of do not occur, I advise to pay no further 
attention to them ; not to be obliged to speculate as to the final causes of things 
is, in a certain sense, an enviable quality. 

"For convenience, let us comprise, in a few short propositions, what we 
have said regarding the etiology. 

" Tumors, like inflammatory neoplasia?, result from irritation of the tissue ; 
the difference in the causes lies : 1. In the specific quality of the irritation. 
Infection of healthy tissue about a tumor, neighboring lymphatic glands, etc., 
is considered sufficient proof of this. It is supposed that, under some un- 
known circumstances, this specific irritant may be formed locally (Rindfleisch). 

57 



914 ORAL DISEASES AND SURGERY. 

while at the same time the epithelial system of an associated glandu- 
lar organ would degenerate in like manner. A tumor of this class, 
if it recurs after removal, presents only the pure carcinomatous ex- 
pression. The sarcomata and carcinomata are viewed by Koster 
as very frequently having common origin in a proliferation of the 
endothelium of the lymphatics of the parts involved. 

Medullary Carcinoma — Encephaloma. — To the mind of the 
writer, encephaloma expresses the very fullness of the cancerous 

I think that, partly as a result of hereditary predisposition, partly from a 
developed tendency, that is, where there is a diathesis, we may imagine the 
formation of materials in the fluids of the body which shall have a specific 
irritant action on one or other tissue. 2. Any, usually an inflammatory, 
irritation may excite a tumor, if the irritated tissue is specifically disposed 
for the development of growths. Virchow, 0. Weber, Rindfleisch, and others 
assume that such specific peculiarities are entirely local and limited to an 
accidentally irritated part of the body, or to a certain system (bones, skin, 
muscle, nerves, etc.). I cannot imagine the localization of such specific 
peculiarities; hence, even with this hypothesis, it seems probable that the 
apparent local specific peculiarities are due to the intimate relations of the 
entire organism. 

" From this representation you may see that the different views only differ 
in the purely hypothetical part. If I entered into the subject more fully 
than seemed necessary for these lectures, it was because this very important 
branch of general pathology has lately been so exhaustively and excellently 
treated of by Virchow, 0. Weber, Rindfleisch, ^Liicke, Thiersch, Plebs, Waldeyer, 
and others, that I considered it necessary to develop more fully those parts 
of my views where I differed from these authors, whose excellent writings I 
cannot too strongly recommend for your stud}\" — Billroth. 

" Carcinoma. — It is one of the most interesting histological problems to 
establish the nature and the manner in which primary carcinoma effects the 
infection of the neighboring lymph-glands, and if that should be proven, 
which for the time being is taken for granted, that this is accomplished by 
means of immigrated cancer-cells, to determine the point at which these cells 
remain attached, and how they produce the first nests of cancer-cells, either 
by their own division, or by infecting the lymph-corpuscles. After numerous 
investigations directed to this point, I can only bring forward that the trans- 
formation of the lymphadenoid substance into the substance of a glandular 
carcinoma is accomplished in an exceedingly simple manner, in that the 
trabecule of the reticulum, like as in chronic induration, experience a con- 
siderable elongation and thickening; the meshes enlarge from ten to twenty 
times, and then, instead of lymph-corpuscles, contain the specific cancer-cells. 
The structure of the lymphadenoid tissue consequently appears to go over 
directly into the structure of carcinoma, the reticulum into the stroma, the 
lymph-corpuscles into the carcinoma-cells." — Rindfleisch. 



TUMORS OF THE MOUTH. 915 

impression. It is as a poison, which, either through its own force, 
or, what amounts to precisely the same thing, non-resistance on 
the part of the patient, overwhelms and quickly destroys ; before it 
all tissues melt away, for none may combat it. Early ulceration 
and the protrusion of fungus nematodes form the common history 
of encephaloma, the cases being exceptional where a patient survives 
over two years. 

Pure encephaloma of the jaws has, in its inception, nothing to 
distinguish it from the most simple of the sarcomata; once started, 
however, the greater activity of the disease soon exhibits itself, 
showing the futility of treatment ; particularly does this find ex- 
pression in the infiltrated appearance of all the surrounding parts. 
If the idea of cutting has suggested itself, it is quickly enough 
dismissed by the entire absence of any distinct line of demarkation. 
One is made to feel that in the absence of a specific he is powerless 
for good. 

Encephaloma does not seem to the author justly described — cer- 

Fig, 278. — An Encephalotd Tumor. 




tainly not at all so from the clinical stand-point — when an impression 
is conveyed of its encapsuled character, for never perhaps is it the 
case that inside of such capsule is confined the heteroclitic expres- 
sion, cells differing from the normal tissue being found infiltrated 



916 



ORAL DISEASES AND SURGERY. 



not only throughout the substance of such capsule, but also in all 
the neighboring parts. 

Fig. 279. — An Encephaloid Expression oe Cancer in a Young Child. 




Section of an encephaloid tumor, as is to be inferred, presents 
varying expression: it is sometimes quite brain-like, or it may, as it 
shades into less malignancy, simulate scirrhus : occasionally it will 



Fig. 280. 



Fig. 281. 



Fig. 282. 






dSill^S'' 




Fig. 280. A microscopic view of the nuclei of soft medullary carcinoma imbedded in a 
molecular basis substance or stroma without cancer-cells. Magnified 500 diameters. (After 
Paget.) 

Fig. 281. A representation of various fully-developed cells and nuclei of medullary 
carcinoma, as seen under the microscope. Magnified 500 diameters. Some of them are 
larger than the average, others more peculiarly slender, elongated, strip-like, or caudate 
cells, with darkly-dotted granular nuclei. (After Paget.) 

Fig. 282. A representation of the dotted nuclei of medullary carcinoma of the breast. 
Magnified 500 diameters. (After Paget.) 



TUMORS OF THE MOUTH. 917 

Fig. 284. Fig. 285. 




^^ 



Fig. 283. A representation of the clustered nuclei of medullary cancer, composed almost 
exclusively of round, shaded nuclei, with three or four shining particles, arranged in 
groups or clusters of five to twenty or more. Magnified about 400 diameters. (After 
Paget.) 

Fig. 2S4. A representation of the caudate and variously elongated cells of a firm medul- 
lary cancer. Magnified 450 diameters. (After Paget.) 

Fig. 285. Small elongated cells and nuclei with a nucleus of the ordinary shape, from a 
firm medullary cancer. Magnified 500 diameters. (After Paget.) 

be colored, such coloring being the pigment-granules of melanosis, - 
melanoid cancer.* 



* The student who is observant of the histological expressions of tumors 
will be much interested in the work now being done in the Surgeon-General's 
Department at Washington, and in the promise by the eminent microscopist, 
Dr. J. J. Woodward, of a series of illustrated papers. Of these papers, 
a first has just been received by the author ; the illustrations, being micro- 
photographic, necessarily insure perfect confidence in their absolute correct- 
ness. 



CHAPTER XLIV. 



EPITHELIOMA. 



Not admitting that epithelial degeneration is necessarily any more 
an expression of the cancer vice than is the degenerated interstitial 
cellular tissue of the fibro- sarcomata, we come now practically to 
demonstrate the truth of the conclusion, by treating of an order of 
cases all of which are epithelial diseases, but not all of which are 
cancer. 

At the clinics of every hospital surgeon are constantly presenting 
cases of tumors or ulcerations associated with the skin or mucous 
membrane, to which are applied the common name of epithe- 
lioma : these conditions differ very much in appearance. When it 
commences in the skin, the disease is apt to present itself in the 
warty or indurated form ; when on clear mucous membrane, as an 
ulcer. Situated upon the lip or anus, having thereby association 
with both skin and mucous membrane, it may present itself in either 
form, or even be pedunculated. 

Fig. 287. 



Fig. 283.— Indura-Ted Epi- 
thelioma. 





Fig. 286, being a case from life, represents an indurated epithe- 
lioma. Fig. 287, also from life, represents the ulcerated variety. 
Theepitheliomata receive the best clinical judgment when viewed 
(918) 



EPITHELIOMA. 



919 



precisely as we have studied tumors ; that is, as self-explaining and 
non-explaining conditions. A common wart, implicating as it does 
in the papillary hypertrophy the associated epiderm, is to such 
extent an epithelioma. An abrading ulcer, whether the result of 
local or constitutional accident, is made to come under the common 
appellation. 

Epithelial degenerations, the result of no explainable cause, are, 
unfortunately, very frequent, and these degenerations have come to 
be esteemed typical of cancer; the various progress, however, and 
conditions of such disease show plainly enough that it is not the 
seat of the disease, but the disease itself, that we are to appreciate. 

Epithelial abrasions from jagged teeth, or from the continuous 
irritation of a pipe-stem, or the clasp of an eye- glass ; from the con- 
tact of filth, as exhibited in the chimney-sweep ; from long-continued 
pressure upon a part ; from wounds, etc., are common enough ; yet 
few of them, comparatively, if judiciously treated, are found to prove 
permanently hurtful. 

On the other hand, epithelial degenerations having primarily 
the most insignificant expression progress to the destruction of 
all neighboring parts and the life of the 
patient, Eig. 288, being from life, and 
having the following history, may be 
presented as an illustration. 

Case I. — Epithelioma of Gum. — 
M. G., aged about twenty-one, farmer by 
occupation, was sent to me about two 
years back by Dr. Edward Townsend, 
whose dental patient he was. Dr. T., 
while treating a bicuspid tooth, remarked 
at the neck a slight ulceration, but which, 
appearing of little consequence, scarcely 
at the time commanded more than a pass- 
ing thought. Attempting, however, at a 

later period, a cure, its obstinacy in yielding excited his suspicions, 
and, being unwilling to assume the trouble of the case, he directed 
the patient to my care. Examination made on first meeting the 
patient revealed a small ulcer on the left superior gum between the 
bicuspid teeth, in size about half as large as the silver three-cent 
piece, jagged, covered with a whitish gummy secretion, and appa- 
rently superficial. The passage of a sharp probe through the centre 
of the ulcer revealed carious, softened, and periosteally denuded 



Fig 288,— View of Case 
as first seen. 




920 ORAL DISEASES AND SURGERY. 

bone. Impressed with the character of the ulceration, yet unwilling 
while there might be an unvefuted doubt, however slight, to depress 
the patient by informing him of the nature of his disease, he was 
placed under ordinary treatment for a period of two weeks, at the 
end of which time, finding the experience in treatment to agree with 
that of Dr. Townsend, his condition was laid before him, immediate 
resection of the affected and adjoining parts being advised. Unwill- 
ing to submit, the patient desired consultation, and in turn the advice 
of every prominent surgeon in the city was obtained. Opinions 
differing, he, b} r advice, submitted himself to various proposed reme- 
dies, being treated two weeks by one gentleman, eight weeks by a 
second, and nine by a third, the disease progressing, though slowly, 
all these weeks. At the end of this time, operation was again proposed 
and insisted upon, the patient being informed of the necessarily in- 
creased magnitude of the portion of bone and soft parts to be removed; 
upon his still refusing, further responsibility in the case was declined. 
The patient making the author a visit at a later period, the ulceration 
was found involving the Stenonian duct and extending from the 
symphysis to the tuberosity of the bone. At this visit he was in- 
formed of the utter hopelessness of any operation for his relief, the 
disease being too extensive. From this time until his death, which 
happened in a few months, he was in the hands of different adver- 
tising impostors. Whether or not an early operation would have 
saved this patient from his early death one may not of a certainty 
say, but from a reasonable experience in the direction, it may be 
asserted that without the performance of such proposed operation 
he had no possible chance. 

The frequency with which the isolated syphilitic epitheliomata 
have been mistaken and treated for cancroid of cancerous expression, 
is known to every surgeon whose opportunities bring him much in 
consultation, while, on the other hand, it has happened directly 
to the author to see at least a hundred cases of the malignant 
or non-explaining condition mistaken for sores of a simple local 
signification.* 

* A vertical section of an ordinary epithelioma shows, at the upper border, 
a scab; if this be detached, a whitish slough-like layer, consisting of loosely 
aggregated epithelial scales, which have been detached from the deeper struc- 
tures, and which may be readily removed by washing. The main substance 
of the growth has commonly a somewhat shining grayish-white hue, is close- 
textured, firm, and rather elastic, and occasionally presents a striped appear- 
ance, due to its papillary structure. Squeezing or scraping brings out a curdy, 



EPITHELIOMA. 921 

Called to the examination of epithelial derangement, the practi- 
tioner may only most rationally seek to explain the condition in the 
discovery of a cause. Not that in the absence of such cause the 
condition is necessarily to be found destructive; such absence may be 
only apparent, the oversight lying in the inability of the surgeon to 
perceive a cause which might be evident enough to closer and truer 
observation. Case II., of which Fig. 286, from life, is an illustration, 
may be offered : 

Mr. N., carpenter by occupation, was sent to the author laboring 
under an indurated tumefaction involving a'full half of the inferior 
lip: the tumor was semi-bluish, slightly lobulated, and painful, had 
existed for over a year, was gradually enlarging and softening. The 
diagnosis of epithelioma but verified the opinion of several other 
practitioners who from time to time had examined it. Recommended 
the removal of the whole lip, which was concurred in by the patient. 
The gap, which was made in the ordinary V-shape, great as it was, 
being carried from either angle of the mouth to the symphysis menti, 

yellowish-white material, which resembles the comedones, or sebaceous con- 
tents of hair-follicles, and which, according to Paget, unlike " cancer juice," 
does not readily become equally diffused when mixed with water. This dis- 
tinction is, however, wanting in the very soft epitheliomata. Epithelioma 
is infiltrated into the tissue in which it occurs, and the normal structure can 
therefore often be traced into the epitheliomatous mass. 

Under the microscope, the characteristic structures of epitheliomata are 
found to consist of (1) cells, which are nucleated, flattened, and scale-like, 
much resembling the ordinary epithelial cells (whence the name of the dis- 
ease), from yJg-o to ^i^ (usually Y ^) of an inch in diameter, and containing 
a few granules, and a clear, round or oval, well-defined nucleus (about j-^-q of 
an inch in diameter), which itself contains granules, but rarely a distinct 
nucleolus ; these cells assume very various forms, being sometimes wrinkled, 
caudate, or elongated, sometimes without nuclei, and sometimes filled with 
oily particles, as if from fatty degeneration ; (2) nuclei, free or imbedded, 
most abundant in the most acute cases, sometimes, like the nuclei, seen in the 
epitheliomatous cells, but sometimes larger, with more distinct nucleoli, and 
much resembling the nuclei of scirrhus or medullary cancer ; (3) brood-cells, 
or cells containing nuclei undergoing development into nucleated cells, the suc- 
cessive formation of one cell within another sometimes giving a peculiar lami- 
nated appearance; and (4) laminated capsules, nests, or epidermic or concentric 
globes, consisting of concentric layers of epithelial scales, containing in the 
central space granular or oily matter, cells, or free nuclei, and apparently 
resulting from a continuation of the process of endogenous cell formation, de- 
scribed as giving a laminated appearance to the simpler brood-cells. These 
nests, or concentric globes, are met with in other epidermic formations, but 
are bettermarked in epitheliomatous than in any other structures. — AsHHURST. 



922 ORAL DISEASES AND SURGERY. 

was filled up without any considerable effort by forcing the cheeks 
toward the mesial line, retaining- them in position by an extempo- 
rized Dewar's compressor, and approximating the edges of the wound 
with the hare-lip pin and suture. The wound united happily by 
first intention throughout, and although at first the stretched tissues 
bound the lower jaw so closely as almost to prevent the patient from 
opening the mouth, yet in three months after the operation the parts 
had accommodated themselves so completely to the new condition 
of things that one would almost fail to detect that the natural parts 
had ever been interfered with. The success of the treatment was 
all that could be desired ; nearly seven years have passed, and there 
is not the slightest evidence of a return of the trouble. 

A case illustrative of the opposite aspect — that is, where a local 
cause is plainly evident, yet destruction to life is the result — is 
shown in Fig. 28?, also taken from life: 

Case III. — Col. W., merchant. Epithelioma involving, when first 
seen, lip, tongue, and cheeks, — case hopeless. The disease in this 
patient began as a minute tubercle just over the genial bodies of the 
inferior maxilla; little was thought about it, and it only received at- 
tention when found ulcerating, such attention consisting in the appli- 
cation of caustics. Aggravated by such treatment, the ulceration com- 
menced rapidly to spread, defying, when too late understood, every 
means employed for its arrest. Shortly after coming under care, the 
lip fell off in mass, the root of the tongue became indurated to such an 
extent as to interfere with both respiration and deglutition, and the 
patient, a fine robust man, died from prostration. In this instance 
the patient for many years had been in the habit of holding the tip 
of his cigar between the tongue and floor of the mouth. Many 
persons, however, so hold cigars without cancerous disease result- 
ing. In such cases, however, no tendency of the kind in the system 
exists to be localized. 

Epithelioma of simple traumatic signification is distinguishable 
from the cancerous specific in the nature of the sore, looking, if not 
too much fretted, like a healthy ulcer, that is, being of a pinkish-red, 
smoothly regular, granulated face. 

Epithelioma of syphilitic expression differs not only from the 
malignant, but also from the traumatic, in having a paste- or film- 
covered bottom. 

Epithelioma of cancerous type is distinguishable from the preced- 
ing classes of ulcers in presenting giant granulations, a fissured 
surface, and most irregular and ragged edges. 



EPITHELIOMA. 923 

The most common seat of epithelial degeneration is the lower 
lip ; after this, the tongue ; the inside of the cheeks is also a very 
frequent seat of the disease. (See Diseases of Tongue*) 

As most commonly met with upon the lip, the condition makes its 
appearance as a simple crack or fissure, — a sore generally of such 
insignificant appearance and inconvenience as to obtain for a long 
period neither attention nor treatment. Aroused, however, sooner or 
later, into activity, its progress is rapid or otherwise, according to 
circumstances which influence it. (See Tumors.^) The moment such 



* For the epitheliomata of the lip, Hutchinson proposes the name "ulcus 
rodens," denying it a cancerous signification, and desiring to class it among 
the non-specific chronic inflammations. 

f In the truly practical and learned work, by Prof. H. H. Smith, on Sur- 
gery, occur the following passages, which may only be read by a student to 
his profound advantage : 

" When, from any cause, irritation is developed in the skin, its appendages, 
or in the mucous membranes, the normal action that daily casts off dead epi- 
thelial cells is increased, and may be followed by hypertrophy, or by such 
thickening, degeneration, and ulcerative action as will materially modify the 
normal condition. Tumors thus formed on the skin and mucous membrane 
by the accumulation of a largely-increased number of epidermic and epithelial 
cells, united together by filaments of fibrous tissue, and furnished with blood- 
vessels, as the result of the organization of the fibrinous deposit, have been 
called, by Hannover, epithelioma. 

" Epithelioma vary considerably in appearance. If the result of the irrita- 
tion caused by pressure on the skin, they constitute corns of common language, 
and are a true hypertrophy of the epidermis. When the epidermic cells are 
closely packed together by pressure, they create hard corns ; when the cells 
are more distinct and disposed to a papillary arrangement, owing to the pres- 
ence of a greater amount of moisture, they form soft corns. 

" When the epidermic cells accumulate upon a surface in consequence of 
the increased action that follows a local congestion or simple redness, they 
form the varieties of skin disease known as the squamaa or scaly class, as 
psoriasis. Condylomata and venereal warts are analogous tumors, usually 
found on the points where the skin and mucous membranes blend, as the corona 
glandis of the penis, the vulva and anus, or about the lips and nostril. Both 
venereal warts and condylomata are developed apparently in some instances 
in consequence of a peculiar contamination. When closely examined, condylo- 
mata are found to be formed of a congeries of papillae, sometimes flattened on 
the top, while others have fissures that lead down to a common stalk. When 
small, condylomata are mostly composed of epithelial scales, but in the larger 
growths there is more or less areolar tissue supplied with small blood-vessels. 
A vertical section exhibits a vascular loop surrounded by a basement mem- 



924 ORAL DISEASES AND SURGERY. 

a sore commences to throw out exuberant granulations, no hesitation 
is to be felt in effecting the most radical removal. 



brane, external to which are layers of epithelial cells that vary in thickness.* 
Common skin warts, as often seen on the hands, belong strictly to the class 
of epithelioma, being formed of epithelial cells not compressed, and of a papil- 
lary form. These are mainly the result of some local irritant that increases, 
on a circumscribed spot, the epidermic cell-action. All these tumors, when 
inflamed, may undergo fatty degeneration, softening, and ulceration, creating 
ichorous and irritating discharges, and sympathetic irritation of adjacent 
lymphatic glands, those of the groin occasionally enlarging from irritated 
corns on the toes, and those of the axilla from inflamed warts on the fingers. 

" The greater vascularity of mucous membranes modifies the formation of 
epithelioma in this tissue, the induration or small scaly wart degenerating 
and ulcerating, and creating, through inflammatory action, more or less indu- 
ration of the parts immediately adjacent. 

" When any irritation develops this action on a mucous membrane, or 
where mucous tissue and skin blend, it is apt to create an ulcerated epithelioma 
that is diflicult to heal. This variety is found on the margin of the lip, in the 
alas of the nostril, in the inner canthus of the eye, after fissure of the nipple, 
on the tip and margin of the tongue, on the os uteri, as well as on the vulva, 
prepuce, and anus. The rodent skin ulcer of the scrotum and lupus are also 
assigned to this same class of growths. When in these localities epithelioma 
is developed, it commences as a flattened induration or scale, which is followed 
by a slight crack or fissure, and an ichorous, watery exudation that is irritating. 
Hence increased action, then ulceration, with induration of the margin, 
so as to give an apparent depth to the ulcer, which is in reality quite super- 
ficial. The pus from this ulcer, being small in quantity, soon dries, and forms 
a scab or scale, which, being accidentally removed, is followed by slight 
bleeding and another crust, the reproduction being in this manner continued 
for months. When these ulcers are examined microscopically, they present 
on the surface masses of epithelial cells in all stages of development. The 
lymphatic glands near these ulcers often enlarge, and are secondarily alfected, 
in consequence of which many writers regard this variety of epithelioma as 
analogous to cancer. That epithelioma may assume the cancerous peculiari- 
ties under some circumstances, is beyond question ; but it is equally certain 
that it is erroneous to regard all epithelioma as cancerous, some of the cases 
being only evidence of disordered epidermic and epithelial cell-action, and 
capable of perfect cure. 

"The opinions of pathologists on the identity of epithelioma and cancer 
are, however, yet much divided, — Paget, Velpeau, and Schuh regarding it as 
cancer, and calling it epithelial cancer, while Lebert, Hannover, Bennet, and 
Lawrence deny its cancerous nature.* Lawrence thus arranges the arguments : 



Bennet's Lectures : and Lawrence on Cancer, 185S. 






EPITHELIOMA. 925 

Appearing- upon the mucous surface of the cheek, anxiety may 
always be felt for the result. The expression is here always more 
or less that of infiltration, and how best to treat the condition is a 
question which repeats itself in every individual case. 

Appearing upon the skin, epithelioma may be esteemed of least 
formidable import. 

Between the epitheliomata there are, as has been suggested, the 
most decided differences in expression, a matter which has been 
studied with most clearness by Thiersch and Koster. Many cases 
are found to remain quite superficial, being strictly external to the 
subcutaneous cellular tissue; these have received the appellation 
of the flat variety. In this form the author would particularly call 
attention to the great benefit to be found in moderate and continuous 
pressure : indeed, if the granulations be first sloughed away with a 

" I. — For Epithelioma being Cancer. 

" 1. Its infiltrating character. 

" 2. Its tendency to infect the lymphatic glands. 

" 8. Its tendency to recur after removal. 

"4. Its fatality. 

" II. — Epithelioma is not Cancer. 

u 1. From the excessively rare occurrence of consecutive deposits. 

'• 2. Its anatomical structure. 

" 3. The absence of primary cachexia. 

" 4. Its frequently local origin. 

" A careful study of the question, seconded by some experience, induces me 
to regard the question as thus correctly stated : 

" 1st. Epithelioma exists as a distinct growth, characterized by epithelial 
cells, as in corns, thickened skin, horns, warts, etc. 

" 2d. These may become the seat of cancerous action, and run the course of 
cancer to degeneration, though in the least marked form, being then well 
designated as 'cancroid.' 

" 3d. There is a cancer of the skin and mucous membranes, originating in 
the follicles, that presents the usual elements of cancerous action elsewhere, 
which yet presents epithelial cells, and the other normal elements of the 
tissue invaded. 

u 4th. Simple epithelioma is to be regarded as really a hypertrophy which, 
when inflamed or irritated, ulcerates and undergoes the usual changes of 
healthy inflammation. 

" When, as is sometimes seen, a sebaceous follicle participates in the in- 
creased epidermic cell-action of epithelioma, it results in a thickened growth 
that is so indurated as to be called a horn. Some of the instances of this 
development, and especially one well known to visitors in Paris, on the fore- 
head of a woman, have attained several inches in length. 



Ml 



926 ORAL DISEASES AND SURGERY. 

caustic of chloride of ziDc, and after the separation of the slough 
the compress be applied, the cases are exceptional where cicatrization 
may not be secured. This result has been again and again demon- 
strated at the University hospital clinic. 

A second form, that alluded to as being most common to the 
cheek, the infiltrated variety, enters the tissues deeply, and is thereby 
rendered the less susceptible to external means ; this is the disease 
in its worst expression. 

A third form, the villous, is most frequently found of direct papil- 
lary signification, and may be treated by extirpation with reasonable 
hopes of a non-return. 

Epithelial growths, as suggested by Billroth, " gland-like in- 
growths, " might be inferred not unfrequently to grow into the spaces 
between the connective-tissue bundles, where lymph circulates, for 
there the tissue offers least resistance. These are the tubes and 
cylinders which Koster thinks he has proved "lie solely in the 
lymphatic vessels." 

The epithelial pearls, described by the histologist, are a result of 
a globular union of cells of the flat variety ; their development being, 
most likely, as has been suggested by Billroth, from the increasing 
division of a number of conglomerate cells, the peripheral layer being 
flattened by pressure against the parts around, which are not very 
distensible. 

Concerning the question of malignancy or non-malignancy of the 
epitheliomata, no more question would seem to exist than in the 
case of tumors or ulcers elsewhere ; indeed, it seems to be a self- 
demonstrating fact that the cancer vice — accepting the humoral 
theory — has the most decided predilection for this tissue ; so has also 
ihe syphilitic, but this does not imply that every ulcer met with 
upon an epithelial surface is either venereal or cancerous. A first 
question, then, always, is to be of the character of the tumor or ulcer. 
(See Syphilitic Ulcers of Gums and of Tongue.) 

Epitheliomata of cancerous character are more common to men 
than to women, and are rarely found to make their appearance about 
the mouth before the fortieth year ; upon the skin, although closely 
restricted to advanced adult life, they are yet to be met with even in 
the quite young. The author has treated a number of cases where 
the patients were not over twenty-three. 

The treatment of the epitheliomata, as will be inferred from what 
has been written, considers the indications of each particular case 
as it may be understood : thus, an ulcer from a wound is to have the 



EPITHELIOMA. 927 

treatment of a wound ; if it be of venereal expression, remedies 
directed to that vice are to be employed. Cancerous epitheliomata 
are either to be soothed and held in abeyance, or treated by the 
most radical operations. 

Whether the radical treatment by excision or by the use of caustics 
is to have preference, would seem to reside with the question 
of location. Where the disease is strictly localized, as seen in the 
early stage of lip-cancer, then excision, always to be made wide and 
free, is to have preference. In the infiltrated variety, on the contrary, 
if attempt at removal seems permissible, it is the experience of the 
writer that the caustics are to be used : trifling, however, is the 
promise from any means. 

Of caustics so used, none may have precedence of the chloride of 
zinc, and this is to be used in its purest form. A cauterization, to 
be of service, must be thorough ; anything less than killing a part 
outright will always be found productive of far more harm than good. 
Of the various substances and means that from time to time have 
been used and applauded, may be mentioned the Yienna paste, nitric 
and hydrochloric acid, arsenic, monochloracetic acid (Atkinson), elec- 
trolysis (Neftel), strangulation, Landolfi's caustic, Mance's paste. 
What particular destructive shall be used amounts, however, to little 
in the way of preference: to kill the parts outright is the indication. 

A practice most frequently and most satisfactorily pursued by the 
author in this direction, consists in covering the part to be acted on 
with the undeliquesced crystals of the chloride of zinc, corroding 
away, by the immediate repetition of this agent, the parts, until the 
diseased scales are all destroyed ; the eschar thus produced is treated 
like any other sloughing wound. When the slough comes awa}^ if 
it be possible, compression is employed. 

Treatment by injection of bromine is commended by Dr. Wynn 
Williams ; a patient exhibited by this practitioner to the Obstetrical 
Society of London, was a person nearly the whole of whose lower 
lip had been removed for epithelioma eighteen months previously. 
The disease shortly appearing in the cicatrix, the growth was suc- 
cessfully treated by two injections of bromine, twenty drops to a 
drachm of spirit. There was no appearance of any return of the 
disease. 

Injections of glacial acetic acid and of Monsel's solutions of iron, 
both of which have been highly recommended, have been submitted 
by the author to the most exhaustive tests. No good results, however, 
have ensued. 



928 ORAL DISEASES AND SURGERY 

Treatment by the knife consists in complete ablation of the dis- 
eased mass. Unless an extirpation may be thorough, thex'e is no excuse 
for attempting such mode of treatment. For the study of the opera- 
tions about the mouth and face, see the chapters on these subjects, 
also the chapter on Diseases of the Tongue. 

In the numberless cases of epithelioma where the most superficial 
observer would recognize the impropriety of attempt at cure by 
operation, it becomes a necessity to support the strength and con- 
tribute to the local comfort of the patient. Here medicines which 
are found most antagonistic to the disease are by all means indicated. 
Of such local means the author would most highly recommend the 
daily use, by means of an atomizer, of the following combination : 

B. — Acidi carbolici, 5j ; 
Soda3 sulphitis, §j ; 
Aquae, §x. M. 

Not only will this preparation be found to afford much relief from 
pain, and to be softening and soothing, but it has seemed to possess 
marked influence in retarding the progress of the disease. It may also 
be administered internally in teaspoonful doses. The American drug 
hydrastis canadensis, used in lotion, is highly commended by Dr. 
Edwin Payne, of London, for its painlessness and for its power in 
keeping the surface in a more healthy condition and free from offensive 
odor. The strength used is a drachm of the tincture to eight ounces 
of water. 

Vallet's mass, administered in doses of from five to ten grains a 
day, has been recommended by Prof. H. H. Smith. One case, as 
an example, is mentioned by this surgeon, where, having been 
consulted with a view to operating, and having declined on account 
of the rapid advance of the disease, he suggested the use of this 
medicine, conjoined with the application of the powdered carbonate 
to the sore, and the patient lived eight years without the disease 
having made any very great progress. 

Justamond, of London, also favored the internal use of iron, and 
was in the habit of giving from sixty to one hundred and twenty 
grains of the ammonio-chloride a day. Dr. Carmichael, of Dublin, 
expressed himself as having derived much benefit from washing the 
ulcerations with a solution of sulphate of iron. 

Chloride of zinc and solutions of the salt are, in this direction, 
favorite preparations : its power to arrest phagedenic action is 
remarkable: the medicine has more than a cauteraut property; it is 



EPITHELIOMA. 929 

peculiarly alterative. Judiciously applied to any indolent, irritable, 
or bad ulcer, it will be found to influence markedly to a change for 
the better. 

Concerning the use of this agent in cancer, we have many com- 
mendations, particularly from European surgeons; but, as can be 
very readily apprehended, nowhere in the range of its application 
is more judgment required for a judicious employment than here, for 
it is a cauterant, a stimulant, an antiseptic, and an alterative. Dr. 
Zuerine, of Vienna, relates a case of cancerous ulceration of the 
septum nasi which threatened to destroy the whole nose; one grain 
and a half of the chloride of zinc, he says, were dissolved in one 
ounce of distilled water, and, the scabs being removed, the" sore was 
penciled over several times a day with the solution ; at the end of a 
fortnight a healthy granulating surface was found underneath the 
thick crust which covered the sore, and this being occasionally re- 
moved, and the solution reapplied, it cicatrized in five weeks. 

Mr. Tuson has published some cases to show the value of cer- 
tain preparations of chlorine in cancerous affections. In one which 
he refers to there was an extensive cancerous affection of the right 
breast and neck, which was treated unsuccessfully for a long time, 
till a paste was applied, made of one part of chloride of zinc to three 
of flour; this was well mixed, and moistened with water, and then 
applied over the ulcerated parts. The zinc was also given internally ; 
half a grain was ordered in a wineglassful of caraway-water every 
morning. The chloride of zinc paste was applied again, and when 
the slough separated, the ulcerated surface healed kindly. The can- 
cerous deposition continued for some time, and the dose of the metal 
was increased to three-quarters of a grain and continued for three 
months. The improvement, although very striking, was not per- 
manent, as the patient suffered a relapse which ended fatally. The 
case, however, was sufficient to show that the treatment had made 
considerable impression on the disease, and especially in healing 
the open cancer, which Mr. Tuson had found to be the result in 
several other cases. 

The great suffering associated with carcinoma makes necessary the 
free use of opiates, both locally and internally. Stramonium, bella- 
donna, aconite, opium and its preparations, hamamelis, are highly 
recommended. As much as twenty grains of sulphate of morphia have 
been administered during the course of a single twenty-four hours in 
certain rare cases. Injections by the subcutaneous method, where 
morphia is to be long continued, are now generally resorted to. 

58 



930 ORAL DISEASES AND SURGERY. 

Batley's solution answers best for this manner of use. For con- 
tinuous stomachic administration of the opiate preparations, prefer- 
ence is to be given to the bi-meconate of morphia; the officinal 
strength of this medicine is that of laudanum, twenty-five drops 
representing one grain of opium. 

A complication sometimes occurring with epithelioma about the 
mouth is the supervention of erysipelas. A peculiarity of thes*e 
cases is that the erysipelas does not exhibit its specific complexion, 
but a patient is found to look as if in a few hours his disease had 
made more progress than before in months, or perhaps in years. 
The best treatment the author has found for such a complication 
consists in the use of what on a previous page has been alluded to 
as almost a specific, — the proportions being varied to suit cases : 

B. — Tincturae ferri chloridi, 3U ; 
Quinise sulphatis, gr. xv; 
Tincturse cinchonse, 3ij to ^ss. M. 
S. To be brushed over the parts. 

Another complication occasionally met with is the existence of 
salivation. The author once had as a patient a lady who was com- 
pelled to keep a wash-bowl constantly upon her lap; the water 
literally flowed from her mouth. 

Of cases of epithelioma, cancerous and otherwise, met with from 
time to time by the author, the most interesting variety might be 
illustrated. Unable, however, to allow more space to the subject, 
the condition must be dismissed, with a suggestion to the inexperi- 
enced to inform themselves of its many and peculiar phases by an 
examination of clinical records ; every service being rich in such 
experience. 



Plate VIII 



Fig. 1. 




i 



PLATE VIII. 

APPEARANCE AND POSITION OF SOME OF THE TUMORS SEEN ABOUT 

THE NECK. 

Fig. 1. — A large Cystoma of the right parotid region, caused by the devel- 
opment of a sebaceous follicle in consequence of a blow upon the 
part. Commencing as a lump the size of a nut, this tumor gradu- 
ally increased to nearly the size of the head; gave exit at one 
time to sebaceous matter ; had a broad base ; was nearly immov- 
able ; had the veins enlarged upon its surface, and showed a small 
ulceration in front, from which fetid, acrid, and bloody sanies had 
escaped. As the tumor enlarged, the jaw became closed, sensation 
of the face diminished, and there were all the other symptoms due 
to pressure on the vessels and nerves of the part. The tumor dif- 
fers in appearance from scirrhus of the parotid gland in its size 
and period of development. It was readily removed, and is rep- 
resented as an example of one of the class of tumors of the parotid 
region not involving the parotid gland. — After Auvert. 

Fig. 2. — Large Adenoid Tumor of the Neck dependent on degeneration of 
the lymphatic glands of the neck. Arising as a small swelling 
caused by an enlarged gland below the angle of the jaw, it gradu- 
ally increased until it occupied the entire side of the neck, in- 
volving many glands, and reaching from above and behind the ear 
to below the clavicle, so as to turn the head to the opposite side. 
Its appearance was that of an irregularly lobulated mass: it was 
unaccompanied by pain, was perfectly firm and hard, and gave no 
sense of fluctuation at any point. Under the use of chloroform 
it was successfully removed by Mott. — After Mott. 

Fig. 3. — Appearance of an immense Adipose or Lipomatous Tumor of the 
Neck. This tumor was not painful ; had no pulsation ; was formed 
of numerous large lobes, with the superficial veins distended over 
them, and was attached to the neck by a large pedicle which ex- 
tended from the angle of the lower jaw on the right side down to 
the sterno-clavicular articulation, its weight being so great that 
the patient could hardly retain the erect position. The tumor was 
found to be covered by a strong capsule formed of the surround- 
ing cellular tissue, and to have originated in a hypertrophy of the 
surrounding adipose tissue. — After Auvert. 

Fig. 4. — A large Cystoma of the left Parotid and Submaxillary Regions, 
which was to the touch semi-elastic, unequally lobulated, and due 
to a chronic irritation of one of the sebaceous follicles, the duct 
of which had become closed, and thus caused a retention and 
degeneration of its secretion. — After A avert. 

(931) 



CHAPTER XLV. 

TUMORS OF PARTS ASSOCIATED WITH THE MOUTH. 

The sebaceous, the cystic, the fatty, and the glandular tumors are 
those most frequently found in association with the integuments. 

The first, the sebaceous, are perhaps the most common, and are 
as simple in nature as they are easy of cure. As the result of a 
blow or other cause, the orifice of one or more of the ducts of the 
sebaceous glands becomes obstructed ; the secretion continuing and 
having no outlet, becomes necessarily accumulated ; hence the grad- 
ual expansion of the duct and formation of a tumor. As this tumor 
continues to enlarge, it becomes more and more solid, the result of 
the absorption, or, if not this, at any rate the disappearance, of its. 
more liquid contents, until finally, to the touch, it becomes springy 
and elastic. A section of such a tumor exhibits a delicate cyst wall 
or envelope, and cheesy or semi-cheesy contents ; it is seen to lie in 
the integument as distinctly as a walnut lies within its hull. 

Sebaceous tumors are found of every size, varying from that of a 
hazel-nut to that of a foetal head ; they are generally spheroidal in 
shape, but frequently, because of influences exerted by neighboring 
parts, become changed, even to a lobulated character. 

The diagnosis of a sebaceous enlargement is generally not at all 
difficult: the tumor rolls under the touch, can be circumscribed by 
the grasp, has a detached feel, as if confined to its place alone by 
the skin ; the tissues enveloping it are perfectly healthy, while, 
however large it may be, no evidences are given of constitutional 
association. Exceptions, however, exist to this simplicity in some 
special cases, as, for example, where the presence of the tumor has 
excited inflammation in the surrounding parts, thickening the cyst 
and forming attachments, or where the attenuated skin has ulcer- 
ated, or where the contents of the cyst have degenerated. 

Sebaceous growths are most easily got clear of by operation. 
In many cases it is only necessary to make a sufficient incision in 
the skin, and the tumor can be enucleated, just as the crystalline 
( 932) 




TUMOBS OF PARTS ASSOCIATED WITH MOUTH. 933 

lens is removed in the operation for hard cataract. In other cases 
it is necessary to incise the tumor through its centre down to the 
base ; this exposes the cyst or sac, which is to be dissected away. 
In instances of moderate or large growths it is the practice to com- 
mence with an elliptical incision, making the skin removed correspond 
with the requirements of the parts after the 
tumor shall have been taken away. In doing 
this it will be found much better to have too 
much than too little integument : even very 
large flaps will be found soon to accommodate 
themselves to the parts beneath. 

The contents of sebaceous tumors, while 
really uniform in character, vaiy greatly not 
only in consistence but in appearance. Yet, 
whatever the expression, the springy, elastic 
character, as the touch is concerned, is pre- 
served. These tumors, while very frequently 
multiform when appearing upon the scalp, Sman sebaceous Tumor, 
where they are known as the common wen, showing its sacculated con- 
seldom appear but as single upon the face. 

Sebaceous tumors have little vascularity, the supply of vessels 
being confined to the sac, which, as will be inferred, is the attenu- 
ated duct and glandular substance : hence the growth is of very 
slow character. Little or no pain attends the development, and 
the enlargement is entirely devoid of danger, as any tendency to 
malignant degeneration is concerned. The sac, because of attach- 
ments which it has formed outside, is generally on such aspect rough 
and cellular-looking; on the inner face, on the contrary, it is smooth 
and glistening. 

Cystic Tumors. — Cystic tumors, or, more correctly speaking, 
cellulose tumors, are of occasional appearance in the cheeks. They 
might be described as a puffiness of the subcutaneous cellular tissue, 
and would be very well represented by considering them as made 
up of a number of air- or serum-injected cells, grouped together, 
and limited by the adjacent fasciae. The skin above such tumors is 
always attenuated and generally discolored, even, at times, to an ap- 
proach to purple, looking, indeed, as if just ready to slough away, and 
yet being tenacious of vitality to an extent quite wonderful. Similar 
tumors are occasionally found in the substance of the lips, but are 
much more apt, in this situation, to be made up of a single cell rather 
than of many. In origin these cysts may be said to be idiopathic, 



934 ORAL DISEASES AND SURGERY. 

coming, as it were, of themselves, and occasionally disappearing as 
spontaneously, having, in the interim, failed to respond in the 
slightest degree to treatment. 

These tumors, unless in situations which permit of the use of the 
knife, which is their effectual cure, are found very difficult to manage : 
the only thing that ever seemed to me of the slightest service was 
the daily smearing of the surface with creasote ointment, and this 
practice will be found unsatisfactory enough. In their treatment I 
have broken up the cells, have laid the tumor open in bulk, and 
stuffed the cavity, have used every conceivable kind of injection, 
and then, completely discouraged and baffled, have left the case to 
nature, which, after six months, or it might be a year or more, would 
finally effect a cure. 

The most common seat of such tumors is over the line of the 
Stenonian duct; and, if I had not succeeded in satisfying myself 
thoroughly to the contrary, I would have to believe that some con- 
nection existed. Whether cured by nature, with or without assist- 
ance, they are peculiarly liable to recur. I have known them appear 
and disappear as many as half a dozen times. They seldom rise 
much above the level of the cheek, are oblong in shape, and, indeed, 
look, at times, more like a varicose vein with hypertrophied valves 
than anything else to which one might compare them. 

Another kind of cystic tumor, appearing in the integuments of 
the face, occasionally met with, may be compared to a cyst of car- 
tilage. Such cysts seem to prefer as a locality the side of the nose, 
and when in this situation are connected with the lateral cartilages. 
If opened from beneath, they will discharge, on compression, a pus- 
like fluid, but, in a very few minutes after such pressure is removed, 
will refill, or will at least reassume their original form, recovering, 
perhaps, by the elasticity which resides in them. 

Another, and the only other, situation in which I have met with 
such tumors, is in the substance of the lip ; but here they more 
resemble fibro-cartilage than when upon the side of the nose. Ex- 
tirpation by the knife is the proper treatment, although it not unfre- 
quently happens that a cure may be effected by cutting into the cyst, 
scarifying its walls, and stuffing with medicated lint; the tincture of 
iodine being used first, and alum-water and capsicum after. The 
illustration, Fig. 290, although not made to show such tumors, is 
almost a photograph of them as occasionally met with. 

Fatty Tumors. — The fatty tumors are much more common to 
the posterior and lateral aspect of the neck than to the face. Wher- 



TUMORS OF PABTS ASSOCIATED WITH MOUTH. 935 



ever they may appear, however, they are recognized by their extreme 
slowness of growth, by the tissues overlying them being unaffected, 
and by the absence of pain and of constitutional association. To the 
touch they are not so expressive, being at one time springy and 
elastic, at another dull and doughy. Being a hypertrophy of the 

Fig. 290. — Cartilaginous Cyst. 




common fatty tissue, these growths are not so distinct and circum- 
scribed as are the sebaceous, consequently are of broader and more 
diffused base ; such tumors may or may not be sacculated, such sac- 
culation, however, referring to a very imperfect cyst even when any 
signs of one may be present. Fatty tumors seldom manifest any 
tendency to degeneration, troubling more from a constantly increas- 
ing bulk, and the annoyance of their presence, than from any real 
harm inflicted. Fig. 3, in Plate VIII., represents a most unusual 
form of the lipomatous tumor. In this instance the growth, from its 
very weight, has become pedunculated, the vascular enlargement 



936 



ORAL DISEASES A^ T D SURGERY. 



Fig. 291. 



being a natural and simple result of mechanical interference with the 
circulation. Fatty tumors are only to be treated by the knife ; it is 
simply a waste of time to try other means. 

Glandular or Adenoid Tumors. — Glandular tumors, repre- 
sented in Plate VIII., Fig. 2, belong 
markedly, although not exclusively, to 
the scrofulous condition, being found 
most generally upon persons so affected. 
These tumors are commonly situated 
upon the side of the neck, involving one 
or more of the superficial ganglionic 
chain. In undecided cases I have 
known them of such torpidity that two 
or three years would scarcely suffice to 
develop them to the size of a walnut, 
while in other cases the enlargement 
will be so rapid that a few months may 
be sufficient to obtain the prominence 
marked in the plate. Unlike the pre- 
vious classes of growth, the adenoid 
tumors are very susceptible to constitutional and local treatment, 
being in such manner quite as frequently caused to disappear as by 
the use of the knife. 

Where they appear upon the face, such tumors imply the enlarge- 
ment of the buccal glands; in these instances they are not so apt to 




Lobulated Lipomatous Tumor — 
after Miller. 



Fig. 292. 



Fig. 293. 




Microscopic Structure of an Adipose 
Tumor (Bennet). 




View of Fatty Tumor removed from 
under the Tongue (Liston). 



have the scrofulous association as when found upon the neck. In 
considering such growths, we are primarily to investigate the cause 



TUMORS OF PARTS ASSOCIATED WITH MOUTH. 937 

or causes exciting to their development. Scrofula, the common 
cause, has been to some extent considered in another part of this 
work ; its general recognition as a dyscrasic disease suggests the 
necessity of such a course of medication as shall tend to restore the 
lost tone and build up the system at large ; hence the use of tonics 
so freely prescribed in such connection. Regarding the local reme- 
dies to be employed, a common preference seems to be given to the 
iodine in tincture. Overstimulation, however, it is not to be forgotten, 
is quite as bad as no stimulation at all, — perhaps even worse ; and 
by a too free use of this agent even more harm than good may be 
done. Harmony in the system at large being secured, it will be 
found to need very little local stimulation to provoke absorption in 
the tumor; hence a philosophical treatment of such cases considers 
not only medicaments proper, but the bath, dress, food, exercise, etc. 

A local treatment to be used in very indolent growths consists of 
equal parts of the belladonna and mercurial ointments. Such an 
ointment, in my experience, causes these tumors to be absorbed very 
rapidly, or else to degenerate into pus. I have used this combination 
in many cases with the most satisfactory results. 

Another mode of treatment is by the blister. For this purpose 
the cantharidal collodion will be found admirably adapted. Blisters 
should be in proportion to the size of the tumor, never covering 
more than an eighth or a quarter of its free surface. 

In cases where it may be thought preferable to use the knife, 
should the tumor be upon the face, the incisions are to be made in 
the line of the underlying muscles, thus insuring the slightest 
possible amount of deformity from the scar. 

Adenitis from a syphilitic association may yield tumors of the 
cervical and buccal glands. A diagnosis in these cases is had 
from the history of the case, or, if this is not to be procured, an 
enlargement will always be found to be associated in the posterior 
cervical chain. This is a most diagnostic sign, and will seldom 
mislead. 

ACCIDENTAL TUMORS. 

Tumors of the parts we are considering, which might be termed 
accidental, are the erectile, the lepidoid, the verrucous, the keloid, 
and the horny. 

Angionoma, Vascular, or Erectile Tumors. — Under this desig- 
nation are included nsevi materni, or mother-marks, and the venous, 
arterial, and capillary growths. 

Nsevi, as suggested by Professor Smith, cannot always come 



988 ORAL DISEASES AND SURGERY. 

justly under the designation of tumors, from the fact that they 
frequently exist without apparent elevation; situated in the skin, 
yet producing no visible thickening of it. These marks are of very 
various size, form, and color, being sometimes found several inches 
in length, and again as mere spots. In form they may represent 
certain familiar objects, as fruits, animals, etc. The color of them, 
generally some shade of red, varies from the arterial scarlet to 
the dull purple of a venous congestion. Naevi, even although to 
the eye they may not in many instances appear vascular, certainly 
differ only in degree from the telangiectasis, being commonly capil- 
lary hypertrophies, as is sufficiently witnessed when wounds occur 
in them. That such vascularity does not, however, shade off into 
the adjoining tissue is sufficiently well recognized; on the contrary, 
the connection is very limited. Such tumors are supplied by two 
or three large vessels, the hypertrophy of whose radicles may, for 
practical purposes, be viewed as constituting the tumor or disease: 
hence, in operating on such growths, if the incisions are made wide 
of the growth, there is perhaps no more than ordinary hemorrhage, 
— only one or two vessels requiring the ligature. 

Arterial Tumor. — This is a form of the erectile growths which 
has an individuality, inasmuch as it consists of a congeries of vas- 
cular twigs, held together by the more or less imperfect remains 
of the associated skin and cellular tissue. That it is not, as has been 
suggested, an aneurism, but rather a simple enlargement of ter- 
minal vessels, is proven by the fact that such enlargement accom- 
panies the vessels of supply for a greater or less distance; that it 
differs, however, from the nasvi, just described, few are prepared to 
admit. It is, perhaps, a formidable nsevus, but it is nothing more, 
both being, in varying degrees, erectile tumors. 

These growths, while in many instances referable to local injuries, 
are in most cases fairly to be presumed of congenital character. It 
is quite true that they may appear even later in life, yet the impress 
existed, although it may have been but a little red spot not larger 
than the head of a pin, and may have entirely escaped attention. 

The growth of such tumors is markedly variable. I have met 
with them where twenty years seemed scarcely to have changed 
their character, while in other instances a single week has exhibited 
alarming progress. In some cases the attenuation of the coats of 
the vessels is so great that one might well imagine he can see the 
flow of the blood, while in other instances a hypertrophy of the 
associate tissues is so marked as comparatively to solidify the part. 



TUMORS OF PARTS ASSOCIATED WITH MOUTH. 939 



In color the arterial tumor will also be found to vary, the shading 
being influenced by the conducting facility of the veins which are 
to pass off the circulation. Pulsation exists in many of the cases, 
and is synchronous with the ventricular systole. To the touch the 
tumors are soft and doughy, almost disappearing under pressure, 
yet filling up the moment such pressure is removed ; they have no 
definite form, the outline being modified by circumstances of which 
we know nothing. One marked diagnostic sign of such tumors 
is the effect produced on the size by the condition of the circula- 
tion; veratrum viride, or digitalis, by lowering the action of the 
heart, will almost cause those of moderate size to disappear. Even 
the quietude of sleep and recumbency markedly affect them. Passion, 
on the other hand, excitement, or any mental emotion disturbing the 
pulse, will cause them to enlarge, even in some instances to burst- 
ing, such enlargement being most pronounced in cases where a state 
of atrophy characterizes the connective tissue. The common danger 
from these tumors is ulceration, which, in many instances, resulting 
in severe hemorrhage, has gradually, and sometimes suddenly, 
exhausted the patient. 

The Venous Tumor. — This is another form of the erectile 
growths, differing, however, from the one just described, in the fact 

that the venous rather than the arte- 

• t , . . , , «, , Tig. 294. — Venous Tumor. 

rial twigs are in a state or enlarge- 
ment. A description of the one is a 
description of the other, save in the 
matters of color and pulsation, the 
latter being generally dark, almost to 
a dull purple or grayish-black, and of 
course deficient in pulsation. Like the 
arterial, the venous tumors are some- 
times slow of growth, at other times 
rapid ; they appear without assign- 
able cause other than the congenital 
impress. 

Treatment. — NaBvi are treated on 
a common principle: by amputation with the knife, by strangulation, 
by starvation, by compression, by injection, and by the application 
of caustic remedies. 

, Excision is chiefly confined to small tumors. In these cases ex- 
cision is the easiest and most rapid way of getting clear of them. 
The general experience to cut as wide of the growth as convenient 




940 



ORAL DISEASES AND SURGERY. 



is the principal rule ; as the vessels of supply are cut, an assistant 
compresses them with thumb or finger; and while such vessels are 
frequently very formidable-looking, yet it may happen that when 
the tumor is entirely away not a single ligature shall be required. 
Should the hemorrhage not cease, it will be found the easiest matter 
to catch them with the forceps or tenaculum and throw a ligature 
around them. 

A removal effected, and the bleeding controlled, nothing remains 
but to close the wound with a few stitches of the interrupted suture, 
and to support it with adhesive strips. 

Strangulation, the most common mode of operation, is effected by 
transfixing the tumor with one or more ligatures,* and thus sloughing 
it away. As a general rule, it will be found necessary to transfix 

Fig. 295. 




skin as well as tumor ; but should cases present where the overlying 
parts are healthy, a crucial incision may be made, and the flaps laid 
off before such transfixion ; the tumor having been removed, the 
flaps are laid back in place, and dressed secundum artem. 



* See Operations on the Tongue. 



TUMORS OF PARTS ASSOCIATED WITH MOUTH. 941 



Fig. 295, being a case treated by Prof. Pancoast, exhibits a large 
vascular tumor of the lip, which found its complete cure in the 
operation practiced ; this consisting simply, as shown in the diagram, 
in passing a pin and compressing upon it the vessels of supply. 

The strangulation of the nsevi not unfrequently requires the exer- 
cise of considerable ingenuity in the arranging of the ligatures. Figs. 
296 and 297 exhibit complexities in transfixion, and will serve as hints 
in practice. 

Fig. 296. Fig. 297. 





Diagram of tumor with its 
base transfixed by a number 
of threads. 



Diagram of tumor with its 
base transfixed by threads at 
right angles to one another. 



Compression applies to pressure, however made. Take a piece of 
ivory, metal, or other convenient material, adapt it to the part, and 
confine by means of bandage or adhesive strips. This mode of cure 
is rarely applicable, being used only over bony surfaces and where 
the tumor is quite small. A practice which in one instance, where 
the tumor was situated upon the finger, answered a satisfactory pur- 
pose, consisted in the daily application of tincture of iodine four 
times the officinal strength, together with the use of an india-rubber 
ring. Collodion, daily applied, has been recommended. 

Injections have many advocates: of agents thus used, the princi- 
pal are iodine, Monsel's solutions of iron, nitric acid, and creasote. 
Such mode of treatment is always, however, more or less attended 
with risk, and is not to be commended. The practitioner disposed 
to try it has only to use the ordinary subcutaneous syringe, break 
up, with its point, the structure of the tumor or some portion of it, 
and follow with the injection. Several cases of death are on record 
from such injections. 

Caustic remedies, used to destroy such tumors, are of various 
kinds, — the Vienna paste being generally preferred ; this is the 



942 ORAL DISEASES AND SURGERY. 

potassa cum calce of the Pharmacopoeia : it is used by making an 
application of from ten to twenty minutes, following it with an 
emollient poultice. 

Another method is to paint the part With the blistering collodion, 
and, after the cuticle is raised, apply crystals of the chloride of zinc. 

In the application of any caustic, trouble, more or less severe, 
from a resulting inflammation, is always to be apprehended; this 
every patient, or the friends, should be made to understand, as it is 
impossible to know just how a case may come out. After the use 
of a caustic and the slough of a part, the resulting wound is to be 
treated as a simple ulcer. 

Starvation is still another method of treating the erectile growths. 
This consists simply in finding the vessel or vessels of supply, and 
cutting off the circulation by ligation ; this mode has many advo- 
cates, and is certainly a good one where the vessels are in a position 
to be conveniently operated on. 

The seton is still another mode. This is introduced by threading 
the needle with tape or other material, and passing it beneath the 
growth. The seton, whatever the material, should be as large as 
the needle which carries it, if not larger; thus, by the pressure 
secured, guarding against hemorrhage. 

In considering the treatment of naevi, it is not to be forgotten that 
there are cases which, if left to themselves long enough, might 
effect self-cure. Young children afflicted with naevus are hurried 
to the surgeon, under the impression that it must necessarily spread, 
and that therefore the sooner the disease is removed the better. 
Such haste will not always be found necessary, or even prudent. 
For a short time after birth a naevus may continue to grow, — for 
several weeks, perhaps ; then it may cease to enlarge. If it is of a 
simple cutaneous variety, it may become the seat of ulceration ; 
this may spread, but it will destroy the naevus. In other instances, 
a naevus, after growing to a considerable size, will become the seat 
of atrophy, — will dwindle, shrink, and degenerate, until little or 
nothing of it is left. 

Treatment of the vascular naevi by the galvanic cautery is at pres- 
ent in much esteem. Dr. Maas, of Breslau, has collected in the Archiv 
fur Klinische Chirurgie (vol. xii.) the histories of one hundred and 
twelve cases of naevus treated by the galvanic cautery. The results 
were as follows : Capillary naevus — cured, 32 ; improved, 1 ; result 
unknown, 1. Cavernous or venous naevus — cured, 72 ; improved, 8 ; 
result unknown, 1 ; died, 3. Arterial or racemose naevus — cured, 



TUMORS OF PARTS ASSOCIATED WITH MOUTH. 943 

2 ; improved, 1. Nasvus combined with other tumors — cured, 6 ; 
improved, 1 ; result unknown, 2. He deduces from the examination 
of the cases the conclusion that the galvanic cautery is followed by 
the best results in neevus, and is much safer than the injection of 
perchloride of iron or any other coagulating fluid. It would, how- 
ever, be wrong to say positively that the remedy is indicated in all 
cases of na3vus. As Virchow has well remarked, the surgeon must 
take the circumstances of each case into consideration. The battery 
used in the cases referred to was that of Middeldorpf. 

In the use of the means of electrolysis, the difficulty to be en- 
countered arises from the fact that occlusion of a venule or other 
radicle seems to have but little influence upon its neighbors, thus 
necessitating repeated operations until the electrolytic action has 
directly influenced almost each individual vessel. Moreover, since 
galvano-puncture thus cauterizes the tissues as well as coagulates 
the blood, it is evident that a slough must ensue, provided the super- 
ficial portion be much affected ; and if such an occurrence must take 
place, with its consequent cicatrix, it is preferable to have it occa- 
sioned by the more speedy action of a ligature. The slough of 
galvano-puncture is, however, perfectly devoid of hemorrhage, since 
it is tardy in its separation ; and it is remarkable for its extreme 
dryness. 

These objections to its use apply only to naevi which are super- 
ficial, or where the skin is implicated. In subcutaneous nsevi the 
operation possesses the advantage of being safer and more certain 
than injection, and in cases where no slough is necessitated we dis- 
pense with the scar of an excision or ligation, — that is, provided 
insulated needles are employed. 

A Bunsen or other battery may be used, the number of needles 
varying with the size of the tumor ; but in all cases care should be 
taken not to carry the action beyond the whitish hue indicative of 
cauterization. In regard to the introduction of gas into the circu- 
lation by this method, I do not think there is the slightest danger 
in cases of naevus, notwithstanding the opinions of Rutherford and 
other able writers on electro-therapeutics. In cases of huge nasvi 
or vascular tumors, this course might be pursued with advantage, 
especially when excision is hazardous.* 

* " Electrolysis.— Drs. Beard and Koekwell, in the Medical Record 
for July 15, 1872, publish some of their results in the use of electricity in 
surgery : 



944 ORAL DISEASES AND SURGERY. 

A method of treating nsevi practiced and highly commended by 
certain English surgeons is that of "piecemeal" removal ; i.e. tear- 
ing the mass away fragment by fragment, the object being to prevent 
hemorrhage, on the same principle as in torsion of arteries. 

In a case of arterial naevus fully the size of a walnut, and grow- 
ing very rapidly, situated upon the cheek of a young babe, a very 
happy cure was effected by strangulation. Two incisions, two 
inches long and crossing each other at right angles, were made 
through the integuments, and the four flaps dissected from off the 
tumor. The knife was then carried through healthy tissue com- 
pletely about the mass, each artery being compressed or picked up 
as it was divided, so that comparatively little blood was lost. As 
the deep portions were reached, it became necessary to lay aside 
the knife, by reason of the size of the arteries, and a strong ligature 
was then thrown around the base, tightly strangulating the remain- 
der and cutting off all nutrition. The wound was dressed with car- 
bolic acid oil, stimulants and anodynes were freely given, and the 



" In the treatment of erectile or vascular tumors, they claim for electrolysis 
the following advantages over the knife or other methods : there is no hemor- 
rhage ; there is no scar ; by proper management, the effect produced is solely 
upon the blood in the tumor ; the operation is easily performed. 

" In proof of this, they adduce cases. 

"1. A child aged eight months, with an erectile tumor in the cheek. Four 
needles introduced for eight minutes. A clot was produced, which was wholly 
absorbed in four months. 

" 2. A large tumor in the hack, in a weakly child aged one year. Same 
operation. Eesult unsatisfactory, as some ulceration followed, and the tumor 
remained. 

"3. A child aged fifteen months, with a tumor near the angle of the mouth. 
Four needles introduced for ten minutes. In four months the tumor had 
disappeared, and no scar was left. 

"4. A subcutaneous erectile tumor at the inner angle of the eye, in a child 
aged sixteen months. Three needles introduced for twenty minutes. Some 
sloughing occurred afterwards, and deformity was left. The authors think 
too strong a current was used, and for too long a time. 

" 5. A child aged eight weeks, with a nsevus on the neck, just below the 
chin. One needle. introduced, and a sponge electrode applied externally, for 
four minutes. Two and a half months afterwards there were signs of reap- 
pearance of the growth. 

"6. Bronchocele of four years' standing, in a girl aged fourteen years. 
External galvanization twice a week for two months failed. Needles intro- 
duced ; in four months, after about twenty applications, a great decrease in 
size in the tumor." 



TUMORS OF PARTS ASSOCIATED WITH MOUTH. 945 

infant soon rallied. On the fifth day the slough separated, and the 
four flaps, which had before been left loose, were then laid in place 
and secured by hare-lip pins and interrupted suture. 

A case of cure of a superficial naevus involving the whole of the 
right cheek of a babe, by an operation performed for the cure of a 
very small and entirely disconnected one situated upon the lateral 
frontal region, occurred only, a short time ago in the clinical practice 
of the author. 

The one upon the cheek was formidable in appearance and size, 
and, while holding its method of cure under deliberation, I operated 
upon the smaller one by strangulation ; this soon sloughed, the base 
rapidly healing: in fact, it pursued the ordinary simple course. 
As this process of sloughing went on, however, a singular series of 
phenomena was noticed to be taking place, almost pari passu, in 
this naevus upon the cheek : it became at first intensely red, then 
purple, advancing to livid, until, as the ligature above dropped off, 
its tegumentary covering also ulcerated, and the whole naevus be- 
came a sloughing mass. By curing the little one above, the large 
one below was cured. 

Melanoid naevi are not unfrequently met with. For an illustrative 
example and consideration of these, see in the foot-note the clinical 
report of a case by Dr. De Forrest Willard.* 

* " M. G-., aged forty-five years. Directly in the centre of the left cheek 
of the woman before you, will be noticed this blue-black growth. It is, as 
you see, oblong in shape, shining and glistening in aspect, and isolated by 
an exact line of demarkation from the surrounding parts. In length it 
measures just one and a half inches; in prominence, half an inch. What 
is it ? We call it a melanoid naevus ; that is, the growth is an ordinary 
naevus, with the addition of a great excess of pigmentary matter ; if it were 
not black it would show itself as one of the species of naevi we have so fre- 
quently had the opportunity of examining together, and every one of you 
would instantly recognize it. It is, then, only the red face painted black. 

" What is pigment? The word is from pingere, to "paint;" it is coloring- 
matter — paint — a something used to color, and is found in varying propor- 
tions throughout the different races of man, being in excess in the African, 
The white race has least — the Mongolian and Indian stand intermediate. 

" The nature of pigment varies, at least as its character is associated with 
the seat of deposit. We find it in a number of places in the human body as 
a normal constituent of the tissues ; in the internal layer of the choroid coat 
of the eye, for instance, there is a dense deposit of these black pigment-cells ? 
forming a dark background to the sensitive retina. 

"This membrana pigmenti is composed of several lamiiue of hexagonal 
cells, which appear of a sooty-brown color, when seen singly under the 

59 



9-46 ORAL DISEASES AXD SURGERY. 

Moles. — Mole? properly belong to the division of the melanoid 
rraevi, consisting as they do of pigmented hypertrophy of the dermis 

microscope, the centre being pellucid, and the pigment-granules variously 
scattered through the cell. It is only in collected numbers that they show 
the true black color. This layer in animals is of considerable depth, and, 
being of metallic brilliancy, is called the tapetum, and gives that well-known 
fiery appearance to the eyes of cats, tigers, etc. in the night. 

•■ In the iris, also, we find pigment of various colors, while again in its 
posterior layer are found those purple cells which, from their resemblance in 
color to a ripe grape, have given it the name of uvea. 

iL The coloring-matter of the hair is another instance; but enough is this 
mention to show that pigment is a normal, healthy constituent of tissues, and 
we will now see where it is found pathologically. 

-•' Pigmental degeneration is not uncommon, and may be well instanced by 
the gradually accumulating black pigment spotting and streaking the lungs ; 
by the bronzing of the skin in the complaint known as Addison's disease, and 
supposed to have some connection with the supra-renal capsules (although a 
case is reported in the Medical Press and Circular for March 8, 1871, in which 
no lesion was found in these bodies) ; by the ash-colored spots sometimes found 
in the mucous membrane of the stomach or intestines of old people ; by the 
black spotting or deposition of these granules in the walls of the arteries, or 
even in the tubes themselves of some animals, which seem to be allied to fatty 
degeneration in our own arteries ; and, finally, even by the frequent granules 
deposited in the arteries of our brains in some instances of disease as recorded 
in Virchow's Archiv, 1859, vol. xvi. p. 564. 

i; A still more morbid condition is seen in pigmental degeneration of mu- 
cous corpuscles in the gray, smoke-colored mucus expectorated at the close of 
bronchitis ; the peculiar color which has usually been ascribed to carbon 
being really due to an abundance of granules in the cells, which closely 
resemble those already spoken of as giving the streaked appearance to the 
lung. Inhaled carbon may be present in such mucus, but the color is not 
entirely at least dependent upon it, since nitric acid or chlorine will cause it 
to entirely disappear. In fibrinous lymph-corpuscles, again, we have another 
evidence of this same degeneration seen in the various shades of black and 
gray which pervade the lymph of peritonitis, which shades are produced, not, 
as formerly supposed, by straining from intestinal gases, but by the incorpo- 
ration of free pigment-granules. [Rokitansky. — De F. "W.] 

" Pigmental adhesions are also spoken of by Paget, in which black spots 
appear like the pigment-marks of the lungs and bronchial glands. 

• ; Pigment-granules of all kinds greatly resemble each other, and are usually 
spherical in form. They are sometimes scattered either sparsely or thickly 
throughout the cells, being also often found in free liquid ; but this may have 
been from an overdistention and rupture of the cells, allowing their escape. 

" Having thus seen that coloring-matter is found both normally and as a 
product of degeneration, let us see if it progresses still further to give rise to 
what we call melanosis. 



TC310RS OF PARTS ASSOCIATED WITH MOUTH. 947 

and epidermis. These growths vary greatly in size and general 
appearance, but are too familiar to every one to need special descrip- 
tion. Usually of congenital relation, they may yet, however, have, 
origin in a long-continued local irritation. If situated upon the 
face — as they are very commonly — their removal becomes a desirable 
matter ; particularly is this the case with the species known as the 
hair-mole, — a truly repulsive deformity. 

" For some reason not clearly understood, an excess of this coloring-matter 
sometimes pathologically centralizes itself, as in the instance before us, and 
we have tumors of various grades of colors, according to the proportion of the 
contained pigmental matter. 

" Now, melanosis is so frequently seen in association with m( dullary cancer 
that we have come, unduly perhaps, to connect it with this, and the name of 
* black cancer' has been given it; but melanosis is not cancer ; it is simply, 
as we understand it, an anatomical perversion, — an expression. The tumor 
before us is not cancerous ; at least not cancerous because it is black instead 
of red ; yet it has an unpleasant look, and, as usual, causes much alarm to the 
patient and friends. 

" That moles and melanoid nsevi do tend or at least are liable to degenerate 
is undoubtedly true ; but in their early stages their structure seems simply 
that of natural skin and epidermis only altered by the deposition of a little 
-coloring-matter . This mole upon the lady's face was simpty a disfigurement 
until recently, when it commenced to grow; and when this stage of activity 
is reached it is time for us to interpose with surgical aid, just as we would 
when a wart takes on epithelial degeneration. 

"As I have said, the cause of the commencement of this active stage is 
undetermined; yet when a constitutional cancerous element is co-allied, then 
these spots seem to be the least able to resist, and degeneration begins, 
accompanied soon by increase in size, and perhaps by twinges of pain. Such 
a stage of activity may, however, never occur, and many such nsevi or moles 
are carried quietly to the grave of persons advanced in years ; and yet even 
at a late day rapid development of the disease may, and has occurred. At 
first such commencing cancer can but be seated in the skin and subcutaneous 
connective tissue, differing only from the ordinary expression in such regions 
by the presence of a little pigment; this is the time for removal. Their 
usual primary occurrence near the seats of natural pigments shows a tendency 
to conformity with the character of the adjacent natural tissues. The melanosis 
of the books cannot be regarded otherwise than as pigmental degeneration of 
cancer expression, the granules to which the color is due filling the cells about 
the nucleus, and finally, perhaps, changing it into a granule mass, thus form- 
ing a parallel in character of action to that undergone in the process of fatty 
degeneration. With the knowledge now that these dark growths are not 
without danger after the commencement of the period of activity, we have 
no hesitation in advising this woman to have this tumor extirpated at once." 
— Author's Clinic. 



948 ORAL DISEASES AND SURGERY. 

When small, no better plan for the removal of these growths can 
be adopted than to circumscribe the tumor by an incision that shall 
reach to the underlying fatty tissue, including by a ligature, which 
shall occupy the line of this incision, the growth, and thus strangu- 
lating it. When, on the contrary, the mole is large, it is best treated 
by being included in an ellipse, which shall extend to such depth as 
to afford a probability of immediate and permanent union of the 
wound. A mole removed by a saucer-shaped out-scooping, leaves, 
in the healing, a cicatrix almost as objectionable as the deformity 
removed. 

Lepidoid Growths. — The lepidoid growths are generally mul- 
tiple, epidermic in character, and exhibit themselves as elevated 
patches of varying size, scattered irregularly over the parts affected, 
the ordinary localities being the cheeks, nose, and forehead. 

The origin of the term, from Xe-tz, a " scale," and devdpov, a "tree," 
affords the idea of the condition the part presents, simply a number 
of scattered bark-like scales separated by healthy skin. The dis- 
ease, without doubt, is most common to persons of sandy and florid 
complexion, having light or reddish hair, with marked cutaneous 
circulation. 

Appearing first as scales not larger than a pin's head, the disease 
may year by year progress, until finally the scales, which, like all 
epithelial tissues, have been falling off and renewing themselves, 
cease to develop, leaving ulcers. The dermis beneath exhibits a 
granular, glossy surface, looking like limited fungi glazed with 
lymph ; the intermediate skin soon becomes deuse and fibro-cartila- 
ginous, and if the disease be not combated a cancerous relation 
shows itself. 

In the treatment of this condition, the paint composed of tincture 
of iron and quinia will be found most reliable. If, however, it 
should not effect an immediate good, it is better to dispense at once 
with its use, and depend strictly upon constitutional influences, the 
arsenicals being employed. As a common wash or simple source of 
protection, bran-water will be found very soothing. A local appli- 
cation, as follows, has also been highly recommended: 

R. — Hydrargyri bichloridi, gr. j ; 
Glyceriuae, 
Aquse Coloniae, aa ^ss. M. 

Molluscous Tumors. — This form of growth, not unfrequently to 
be seen upon the face, derives its name from the excrescences met 






TUMORS OF PARTS ASSOCIATED WITH MOUTH. 949 

with on maple-trees, which in appearance it very much resembles. 
In color this tumor varies from a brown to a red, being most com- 
monly, however, of a dusky yellow : in character it is epithelioma- 
tous, originating, probably, in alterations of the reflected dermis and 
epidermis lining the hair-follicles. 

As these tumors seldom attain a size greater than that of an ordi- 
nary pea, the quickest and safest cure is in ablation, either by knife 
or ligature. 

Verrucous Growths — Warts. — Warts upon the alse of the nose 
are familiar objects to every one. They consist of an hypertrophy 
of the papillary structure, and are frequently covered with a sort of 
secondary growth, as in what are known as the seed-warts; the 
structure is essentially cellulo-fibrous. 

Warts are not only objectionable on account of the deformity they 
produce, but when situated upon the face they seem peculiarly 
inclined to degenerate, assuming a vascularity which always im- 
presses as threatening. In treating a wart, the practitioner may, if 
he choose, first apply dilute chromic acid ; this, in many instances, 
will blacken and kill the growth, the tumor sloughing away in the 
course of five or six days, leaving the resulting ulcer a perfectly 
simple one. But chromic acid is not to be applied to the vascular 
wart ; on the ^contrary, if irritable, as generally first seen by the 
practitioner, it is to be soothed by the gentlest of applications, after 
which it is to be thoroughly removed with the knife or ligature. A 
good rule in this direction is, " Do not irritate." I have seen many 
a vascular wart provoked into the most alarming aspect. A wart 
situated upon the face, unless like the simple, hard, insensible ex- 
crescence met with upon the hands, cannot be too carefully or 
judiciously treated. 

Keloid Tumors. — Keloide, the French term, signifying a disease 
resembling scirrhus, is the name given to one of the most peculiar 
and inexplicable of the skin affections. This condition, first de- 
scribed by Alibert, is characterized by nodules, or more generally 
wheals, scattered irregularly over the body, — usually, however, con- 
fined to the breast, arms, neck, and face. It occurs in both sexes, 
may appear at any time of life, and is thought to be more common 
to the black than to the white. 

Keloid is a disease of the skin and subcutaneous cellular tissue. 
That it is an atonic condition I infer from the fact that in every 
individual case in which I have seen it there seemed to be a scrofu- 



950 



ORAL DISEASES AND SVRGERF. 



lous association. This, however, may have been accidental, as I do 
not find it referred to by others. 

As to the exciting causes of keloid, dermatologists express no 
opinion: it is traumatic, and it is idiopathic ; it appears upon a skin 
which before has seemed entirely healthy, and it springs up in the 
cicatricial tissue of a wound. The cicatrices of bad burns from dry 
heat very frequently so simulate this disease that one might be 
readily mistaken for the other. Keloid certainly constitutes a dia- 
thesis : I have seen it develop after a simple puncture which opened 
a boil, while others have remarked it appearing in the cicatrices of 
smallpox, after scarification in cupping, after vaccination, blistering, 
etc. Processes or roots pass into neighboring parts, thus extending 
the disease ; the excrescences, to the touch, are hard, semi-elastic, 
and rough ; the color differs from that of the surrounding parts — 
varying as do the cicatrices of burns. According to some observers,, 
the parts itch and are more or less uncomfortable. I have myself, 
however, never heard complaint of any peculiar sensation, except, 
indeed, as the location of some wheal would interfere by its stiffness 
with free motion in a part. 

A keloid tumor seems to be an imperfect fibrous development, a 
species of fibroma. 

Treatment. — This has, in every instance, proved so unsatisfac- 

Fig. 298. — Keloid Boa of Xeck. 




tory, that surgeons are agreed in the practice of letting them alone : 
even the knife is useless, or worse than useless; if a nodule or wheal 



TUMORS OF PARTS ASSOCIATED WITH MOUTH. 951 

be removed, one, or perhaps half a dozen, will spring up in its place. 
Where the tumors interfere much with motion, they may be lubri- 
cated with glycerin or oil, but otherwise nothing can be effected by 
treatment: the only comforting reflection for the patient is that 
keloid seldom, if ever, degenerates into cancer. 

Hornlike Tumors. — These tumors, in the proportion of one-half 
the cases, appear upon the face, — most frequently upon the forehead 
and lips. In size, as well as in general appearance, the greatest 
variety is presented. Allowed to grow, they have been met with 
measuring seventeen inches in length. In the British Museum is a 
specimen eleven inches in length by two and a half inches in cir- 
cumference. A case is recorded in American practice where such a 
growth measured fourteen inches in circumference at its shaft, and 
branched into three divisions. 

A horny tumor is an epithelioma, and finds its analogue in the 
human nails. Treatment is by excision, which, if thorough, is to be 
depended on for a perfect cure. 



CHAPTER XLTI. 

OPERATIONS UPON THE LIPS AND CHEEK. 

Hare-lip. — This defect consists in a break, single or double, in 
the continuity of the lip. The deficiency in its typal form is almost 
precisely similar to that which exists naturally in the hare and 
rabbit, having from this resemblance taken its name. When con- 
genital, it is always found associated with the superior lip. 

A general view of the operation for the relief of hare-lip, and 
indeed the view which comprises the principles of the cure, is, that 
the margins of the cleft or break are to be pared, brought together, 
and held in apposition until nature shall secure a union. There are. 
however, nice surgico-artistic associations which are to be studied in 
connection with such principles of operation. Cutting manipulations 
upon the face, and especially about the lips, claim more than ordi- 
nary skill and judgment. Such skill and judgment the practitioner 
should be prepared to exercise, if not for humanity's sake, at least 
for his own credit and reputation ; for, as is truly remarked by the 
skillful surgeon, Mr. Skey, " on the more or less perfect result of 
such operations depend the appearance and expression of the patient 
for life." And surely, just so far as an operator shall beautify or 
mar, is the comfort of the patient, as well as his own reputation, 
influenced. 

A proper and comprehensive study of hare-lip divides itself 
naturally into three subjects of special signification : 

1st. The time of life best suited to the operation. (Considered in 
foot-note.*) 

2d. The condition of the patient. 

3d. The mode of operating. 

- ' ; I advise you," says Mr. Liston, " to defer the operation till the first set 
of teeth come in, and I have seen good reasons for adhering to such rule. 
When the operation is undertaken at an early period, there is often great 
difliculty ; sometimes union does not take place, the parts turn out again, and 
the patient is rendered more deformed than in the first instance. "When the 
features are enlarged somewhat, you have more ground to work upon : you 
(952) 



OPEBATIONS UP OX THE LIPS AND CHEEK. 953 

In making up the sum of an operation, the operator is to con- 
sider, regardless of the age of the patient, the amount of shock such 

can put the parts then neatly together, and you can almost answer positively 
for the union taking place. I operated," continues this gentleman, "on a 
child, the other day, in whom the operation had been performed twelve 
months ago. The parents were anxious to have it performed, but I then re- 
fused ; it was done, however; but the moment the pins were removed, the 
lip turned out as before." 

" For my own part," says Mr. Bransby Cooper, " I entirely agree with Sir 
Astley Cooper, in regarding it as unsafe to operate on infants before weaning : 
first, because, from their excessive irritability, th'ey are totally unable to sus- 
tain any loss of blood; and secondly, because, after the operation, they are 
rendered incapable of sucking; and, indeed, Sir Astley has pointed out, in 
his lectures, the frequency of the failures he met with in his own practice, 
in operating upon infants shortly after birth. I consider the best time, under 
ordinary circumstances, to be soon after the child is weaned, as it is then 
capable of receiving nourishment independently of its mother, and has over- 
come the distress incidental to the separation from her." 

Dr. Houston, of London, in examining the question as to the period of life 
best fitted for the performance of the operation, decides in favor of the third 
month after birth ; urging, as his reasons, that the parts recover themselves 
better than when the operation is performed later in life ; that the lip in due 
time acquires fullness and pliancy ; the nose is prevented from assuming a 
spread-out, ugly appearance ; the fissure in the palate, if there be any, closes 
greatly with the growth, if supported by a firm and perfect lip ; bad habits 
of speaking, such as guttural or nasal utterance, which if once established 
become irremediable, are avoided; and by removing the disfiguration before 
the child is conscious of its existence, it is spared the feelings of humiliation 
which the consciousness of such an infirmity necessarily imparts, and which 
invariably gives a tone to the character of the individual. He states that he 
has operated on several infants three months old, with equal success in all 
cases, and has never failed. 

Dupuytren recommends the third month ; Velpeau, the first six ; but if 
that be already passed, he defers operating until the tenth or fifteenth year. 

Skey, differing from Yelpeau, says, "The operation may be performed at 
almost any age, but should not be undertaken under about six months." 

" The period of life," says Mr. Fergusson, "which I think very eligible 
for these operations, is either before the teeth begin to show through the gums, 
or shortly after the child has ceased to suck, provided the health seems good. 
If the patient is allowed to grow up, he is usually unmanageable until after 
the age of puberty ; but, if possible, the malformation should always be put 
right before this time, as there is a better chance of the gum and nose as- 
suming a good shape than after they have arrived at their full development. 
Indeed," continues Mr. Fergusson, " there are so many advantages besides 
these — as to speaking, appearance, etc. — that it is wonderful any surgeon can 
recommend delay in such cases after the first or second year of life. I have 



954 ORAL DISEASES AND SURGERY. 

operation is to give, and the ability of the patient to bear this shock. 
This at once brings up the character of the defect, and the amount 

myself," says Mr. Fergusson, i! operated frequently -within the first three 
months, and in some of these instances seen the child take the breast readily, 
with the pins still in the lip." 

Dr. J. Mason "Warren has operated on infants only a few days old, with 
perfect success. Professor P. Dubois read before the Academy of Medicine 
of Paris a paper on this subject, and referred to seven instances which had 
come under his notice, where the proceedings had been resorted to, and suc- 
cessfully, within the first few days after birth ; and Malgaigne has followed 
a similar practice. 

" Prom all my experience and reflections," deduces Mr. Fergusson, " I am 
more than ever disposed to recommend a very early operation. Within the 
last twelve months I have operated on five infants, all of them under three 
months, with the most satisfactory results ; and these cases, with others I have 
previously had, are sufficient to induce me to pursue a similar practice in all 
instances of the kind which may come under my notice, unless there be some 
apparent indication not to interfere. An erroneous impression, as I suppose, 
prevails that children are remarkably subject to convulsions while undergoing 
operations ; and this is often urged as a reason for not interfering with a hare- 
lip in early life. Doubtless convulsions have occurred in some of these cases : 
but similar effects have been produced in the adult, and by less formidable 
means, too. Sir Astley Cooper has referred to several examples of this kind, 
but I imagine they must be rare indeed. I once asked Dr. Abercrombie. of 
Edinburgh, the result of his experience on this point, and he could not bring 
a single instance to his recollection where convulsions could be fairly attrib- 
uted to an operation." 

• ; At what period," says Colles, the famous Dublin professor, " should one 
undertake the operation for hare-lip ? Xo doubt the earlier you perform it 
the better chance you will have of a speedy cure ; but infants at a very early 
age do not bear operations well ; many of them will be seized with convul- 
sions, and die, if subjected to a more trifling operation than this we have 
been considering. I think between the second and third year is the best 
period." 

Prof. D. H. Agnew operates at any period : is influenced only, even during 
the process of dentition, by constitutional condition. If dentition is pro- 
gressing quietly, that is, if there is no associated irritability, he can see no 
reason why the operation may not be performed just as well at this time as at 
any other ; has operated in all the stages of this process. Dr. Agnew prefers, 
however, early operations ; he thinks that his most successful cases have been 
on children who had not attained their tenth day. So far as interference 
with sucking is concerned, he remarks that he has seen a child take the breast 
almost immediately after an operation has been completed. 

Professor Pancoast entertains about the same views as are expressed by Dr. 
Agnew. Dr. Pancoast gives it as the result of his very extended experience, 
that the operation may be about as well done at one time as at another: 



OPERATIONS UPON THE LIPS AND CHEEK. 955 

of operative proceeding necessary to its cure. A bad double cleft 
would inflict a much greater amount of pain than a simple single 
one, and consequently would inflict a shock double or treble in force 
to the last. Now, every man, woman, and child in the world has a 
certain amount of physique, and no more. The experience and phy- 
siological knowledge of the surgeon should enable him to weigh 
this life-force. He must then decide, in the first place, whether or 
not his patient is equal in such force to the demands of a proposed 
operation. He must consider the condition of his patient. This 
brings up the second of the special propositions or stand-points from 
which the operation is to be studied. The possession of a capable 
physique does not imply that the life-force has not, like the tide, its ebb 
and flow. A child may have proper development, yet at the very 
time when it is presented for operation it may labor under temporary 
depression, the result, perhaps, of functional disturbances. A child, 
for example, just convalescent from cholera infantum, or just recovered 
from some of the exanthemata, would certainly not be so fit a sub- 
does not see why the period of dentition is to be so cautiously avoided ; 
operates at any period of this process, if there are no contra-indications of 
constitutional disturbance ; has operated on many children as early as a few 
days after birth, with the happiest results ; does not find the operation inter- 
fere materially with nursing. 

Professor Henry H. Smith, of the University of Pennsylvania, says, "As 
respects the period for the operation, the earliest possible time after the tissues 
seem firm is to be selected, usually after the third month of infancy." 

Now, although I have here cited such a variety of opinions, which, to the 
inexperienced, may seem confusing, yet, when we consider the different 
circumstances under which these learned and experienced gentlemen have 
written and spoken, we are enabled to deduce from such experiences rules for 
guidance, in which, if my observation at all serves me, will be found data as 
reliable as we could well expect to possess. The views of such as I have men- 
tioned will be found to represent fairly the diversity of opinion existing 
throughout the profession. These well-known authorities have been especi- 
ally selected, because, being public teachers and writers, their views in extenso 
are thereby made the more easy to come at by any reader specially interested 
in this subject. 

The author, who has operated upon such number and conditions of hare- 
lip as to give him full confidence in his own experience, prefers that period 
which precedes the eruption of the first teeth. In babes of such age, he has 
frequently been able to remove the first pin in twenty-four hours, and the 
remainder at the end of the second clay. Any time, then, he would say, 
between the fourth week and sixth month is to be considered the period of 
selection. The operation, however, may be performed at any time. (See 
text.) 



956 ORAL DISEASES AND SURG ERF. 

ject for operation as though it had not suffered ; it may have borne 
the demands made upon it very well, and come out of the ordeal 
looking strong ; but then it is the last feather that breaks the camel's 
back ; the system that endured bravely the one demand may not have 
a residue of force on hand that will just then meet another. Give 
such a system time ; get it back to the condition in which the first 
demand found it, and you then have it certainly capable of the same 
resistance and of the same endurance. Again, a patient may not be 
up to the required tone, and yet circumstances may render a speedy 
operation desirable. We can assist nature. Exercise, fresh air, and 
proper food can do much. The last may imply that the milk of the 
mother, if the child be nursing, be exchanged for that of the hired 
nurse. Who has not examined the milk of a mother or wet-nurse 
and found it greatly deficient in some important constituent? The 
author has seen babes growing weaker and more puny day by day ; 
has seen physicians baffled because they could find no one portion of 
the economy less healthy than another. He has seen the microscopist 
take the milk on which such a babe has been feeding, and, looking 
at it through his glasses, find large quantities of colostrum. A 
change of milk has effected an immediate change in the health of the 
child. A child may have fibrinous blood to excess, tending to undue 
circulatory excitement, or the lymph which such blood would exude 
might be so corpuscular in character that a wound would at once 
take on suppurative action. Either condition would be adverse to 
an operation. Yet we have alteratives for the one, and tonics for 
the other. A seemingly strong child may be in a typhoid state, 
and a blushing cheek may be but the effect of hectic or excitement; 
typhoid blood has, comparatively, no fibrin. If you were to perform 
an operation on a patient so conditioned, you would be sure to have 
a failure for your pains. The writer has had under care patients in 
just such a typhoid state; the pulse would be bounding and the face 
always flushed: such a quick pulse and flush is, however, the result 
of the very deficiency in the blood. A child may be cutting its 
teeth, yet this does not necessarily contra-indicate an operation. It 
is not every child that has convulsions and kindred troubles with 
the cutting of its teeth ; many an infant goes through the whole pro- 
cess of dentition without cause upon which to ground a sob. If a 
child is brought to the surgeon, cutting teeth, with an operation for 
hare-lip to be performed, and there is associated with the dentition 
no general or special local disturbance, why should he not proceed, 
caeteris paribus, at once to operate? There are no objections to so 
doing-. 



OPEBATIONS UPON THE LIPS AND CHEEK. 957 



Fig. 299. 




Elliptical incision in the operation for 
hare-lip. 



The next consideration is the operation itself, — the modifications 
of the one principal operation, and the variety of clefts influencing 
such modifications. 

A basis operation might best be represented by a simple Y-cleft, 
having the mesian line of the lip as its centre, — the indication being 
to restore such lip to a normal con- 
tour. (See Fig. 299.) On examination, 
we find that a normal lip has no break 
in its continuity ; we find what may 
be termed the centre of the lip repre- 
sented at its free margin by a projec- 
tion of more or less graceful curve. 
We find, extending from this free 
margin up to the nares, and bounded 
laterally by the alse nasi, a fossa, — 
the fossa labialis. From this fossa we find the lip on either side 
spreading itself out to be lost in the cheek. To meet the indications 
of this case we mast remedy the break in the continuity, create a 
mesial projection, and give to the centre a fossa. To fulfill such 
indications requires a study of the conditions from a surgico-artistic 
stand-point. We want, first, to correct the cleft. This in itself is 
easy of accomplishment ; we have only to pare the edges arid sew, 
or pin, the raw surfaces together. But in viewing this first step a 
little more closely, we perceive that a common Y-paring from the 
edges of the V-break would defeat our purpose in securing either 
a centre fossa or a mesial projection ; the mode of bringing the parts 
together would put on the stretch such fibres of the orbicular muscle 
as are associated with the margin of the lip, while all that portion 
farther up would be comparatively relaxed ; thus our fossa would 
be a promontory, and our soft median swell would be a stretched 
mucous membrane. Such an operation would, then, in meeting the 
first indication, destroy our ability to fulfill the two others. We 
must, therefore, instead of the V-cut, seek a better ; for on the way 
in which we pare our edges depends the fulfillment of all three of 
the indications. An ellipse suggests itself, and such a paring will, 
measurably, meet our wants. 1st. It enables us to bring the edges 
of the cleft together. 2d. The centre of the ellipse is its greatest 
diameter, and this centre is the centre of the lip. When we bring 
together this most widely separated part, it necessarily projects the 
most yielding surface — and such surface is the free symphysis of the 
lip ; thus the second indication is met. 3d. The greatest stretch on 



958 ORAL DISEASES AND SURGERY. 

the muscle is in the site of the myrtiforni fossa, with a necessary 
relaxation above and below ; and thus the last indication is met ; 
for, as the result of such a condition of the parts, we have a fossa 
formed and a promontory at the free mesial line. 

Remarks. — The paring of a cleft should always be constant in the 
one feature of being Y-shaped, as reference is had to the base of the 
Y looking toward the throat ; this allows for excess in the retrac- 
tion of the skin over the mucous membrane. If this precaution is 
neglected, a difficulty is likely to be experienced in the gaping of the 
cutaneous portion of the wound. 

The subject of retaining the parts in apposition, with regard 
to suture material, has elicited much controversy. The ordinary 
operation is as follows. After you have pared the edges of the cleft, 
take up a needle threaded with the ordinary waxed silk, pass this 
through the free margins of the lip and bring the parts together ; 
this is to insure a satisfactory approximation at this point. Next 
take two ordinary steel pins and pass them at equidistant points on 
the lip, — they must go, in depth, at least half its thickness ; these 
pins are to enter and emerge at least five lines on each side of the 
fissure. Silk ligature stuff, in the shape of the figure-of-8, is now 
to be passed about and around these pins. (See Plate IX., Fig. 5.) 
Adhesive strips are next passed over the pins, a slit being made for 
their accommodation ; the object of these strips is to press tissue 
toward the wound, preventing, through such support, undue tension. 
If blood oozes out and clots upon the ligatures, it has been considered 
rather favorable than otherwise, as it has been thought to add to the 
support of the parts. After two or three days the pins are carefully 
removed by a rotatory motion ; the ligature material and adhesive 
strips are allowed to remain from four days to a week longer. 

Yarious means have been suggested to be employed in lieu of the 
pin and figure-of-8 dressing, objection to such dressing certainly ex- 
isting in ulceration apt to associate with the pressure induced by 
swelling. Prof. Agnew uses silver wire. He simply sews the parts 
together with a greater or less number of interrupted sutures. He 
thinks such sutures possess great advantages over the pins. 

Another means of bringing the parts together which has been 
suggested, consists in the employment of the interrupted suture of 
silk used from the under surface of the lip. In such use of the hid- 
den suture nice approximation and support are to be given the face 
of the wound. 

Dr. Washington Atlee has suggested a suture which differs only 



OPERATIONS UPON THE LIPS AND CHEEK. 959 

from the ordinary pin and figure-of-8 in that he employs rings of 
india-rubber, which are stretched over the pins. This suture for 
many purposes must prove an admirable addition to the armamenta- 
rium chirurgicum ; but in hare-lip operations it has no advantage 
over the ordinary figure-of-8, inasmuch as the same strain, if not a 
greater, is exerted upon the points at which the rubber is supported 
by the pins. The merit claimed for this suture is, that whether a 
part swells or remains normal, the compressing force continues about 
the same. 

A mode of securing the apposition of the parts, which will be 
found very satisfactory, is to take three, four, or more threads of 
silver wire, — the fewer you can get along with the better, — the gauge 
being the most delicate that can be procured ; pass these and let 
them emerge at lines which shall very nearly correspond with the 
commissure of the lips. Next take a strip of common sheet-lead, 
and, cutting it to an appropriate size, make in it as many little holes 
as you have threads to either side ; pass the threads through 
these holes, and compress on each a McLeon button — i.e. a simple 
flat shot. Now, with the fingers, nicely approximate the wound. 
This satisfactorily accomplished, draw up the. wires and fix them on 
a second piece of sheet-lead, as in the first instance. If the centre, 
which is the line of the wound, tends to bulge forward, a delicate 
compress is to be placed over it, and bound to its place by an adhe- 
sive strip. The advantages of this dressing are, that it may be 
retained for weeks, if necessary; it is entirely unirritating ; the 
wound is perfectly open to examination ; and, more than all this, the 
threads, being unirritating and very slight, when taken away leave 
no scars. 

A still happier dressing, but one which can be applied only on 
such patients as have reached the age of intelligence, is a modifica- 
tion on Dewar's dressing. Hainsby's compressor may be likened 
to the ordinary double hernia truss. It consists simply of a spring 
which passes around the head, having a small pad at each extremity. 
The piece is of such circle and character as to bring the pads to the 
labial commissures. The instrument is held in position by any con- 
venient means. Dewar holds it by what might be termed a fronto- 
sagitto-lambdoidal sling. The process of dressing with this instru- 
ment would be as follows. After making the paring of the cleft, 
cleanse the parts well with cold water (controlling hemorrhage by 
pressure on the facial arteries) ; next take a strand of the common 
silk ligature material, and nicely approximate the free edges of the 



960 



ORAL DISEASES AND SURGERY 



lip, passing the needle on the under side. The next step is the 
application of the compressor. With the thumb and finger now force 
the tissue of the cheeks toward the mesial line of the lip — this ap- 
proximates perfectly the edges of the wound ; replace your fingers 
by the compressor, and the parts are held in situ. If the approxi- 
mation of the wound thus made should not, however, be satisfactory, 
secondary compresses of linen may be placed more immediately 

Pig 800. — Hainsby's Compressor. 




about the wound, and fixed by a delicate roller. The advantages of 
this dressing will be at once apparent. There are no pins or liga- 
tures used, consequently there is nothing to interfere with direct 
union ; there are no punctures made in the skin ; of course there is 
no risk of having any but the single linear scar, and even this, if 
direct union is secured, must be slight indeed. The parts can be 
examined at any time without important interference with the 
apparatus.* 

In some individuals the coronary arteries are quite large. To 
suppress the hemorrhage from these vessels, dependence is generally 
placed on the pressure exerted in bringing together the edges of the 



* This description does not, as is seen, accord fully with the diagram ; the- 
pin and figure-of-8 being shown. The drawing has been utilized to show the- 
feature of the ordinary dressing. 



OPERATIONS UPON THE LIPS AND CHEEK, 961 

wound. If such pressure does not answer, or if we should prefer 
some dressing that will not make this pressure, light ligatures may- 
be thrown around the vessels, one end to be cut off, the other to be 
brought out at the back part of the wound. Ligatures, however, 
are to be avoided when possible, as they interfere with proper 
union. 

A much better means than the resort to the ligature is compres- 
sion of the facial arteries. Such compression needs to be kept up 
but for a short time, as the smaller vessels soon contract. Hainsby's 
compress controls the hemorrhage by its pressure on the coronary 
arteries, and its action may be very readily imitated with a common 
compress and roller. 

There is a feature associated with the formation of the linear 
cicatrix, and the unsightly notch which so commonly deforms hare- 
lip patients, that I do not remember to have ever seen alluded to, 
but which is of such consequence as to merit the closest scrutiny. 
Is it the fault of nature or the fault of the surgeon that the opera- 
tion gives any cicatrix at all ? Cicatricial tissue — tissu inodulaire T 
as Delpech more happily terms it — means accidental tissue, — new 
tissue formed from granulations. The existence of inodular tissue- 
implies, as it is greater or less in amount, that a wound has healed 
either by primary or secondary adhesion, and certainly not by what 
Mr. Hunter terms union by first intention, or what Mr. Paget calls 
immediate union. If a wound is made to unite by first intention, 
there cannot possibly be any observable inodular tissue or scar, be- 
cause so little new tissue has been formed, blood-vessels and nerves- 
have been brought into perfect contact, and the harmony of the parts^ 
has been so completely restored that after a few weeks the closest 
observation fails to discover the seat of accident. We have familiar 
examples of such union in the slight cuts we are constantly giving 
ourselves with the razor, the cuts we get about the fingers, etc. 
Some years back the author removed from the parotid region of a 
young man a tumor fully the size of a hen's egg. The flaps were 
adjusted with the greatest care, and held in place by compresses of 
old and fine linen. Ten weeks after the operation the union was 
found to be so immediate that it was impossible to say where the 
cut had been made.* 

The union of a wound by adhesion or by granulation implies a 

* Mr. Paget mentions very large wounds that not unfrequently lieal in this 
perfect manner. One case, that of a lady who had been operated on for scir- 

60 



962 ORAL DISEASES AXD SURGERY. 

certain amount of inflammatory action, and the exudation and 
organization of lymph. This is the way in which hare-lip wounds 
are healed, and this is why we have the linear cicatrix ; and not only 
the cicatrix, but, according as the union has simulated or departed 
from the immediate type, we have necessarily a great or a small 
notch. 

But how is the notch formed ? The explanation is simple enough ; 
but it is not that generally given ; at least, I think not. The notch 
is the result of the natural contraction which belongs to fibrous 
tissue, of which fibrous tissue the cicatrix is formed ; and if we ob- 
serve, we will find that where this linear inodular tissue exists in 
excess, a large notch is always associated with it. If we need 
further proof to convince ourselves that such contraction is the 
cause of the notch, we have only to remark that in cases of large 
cicatrices the destruction of the symmetry of all the surrounding 
parts has invariably occurred ; the contraction has puckered, as it 
were, the whole part. "When a linear cicatrix is very limited, the 
notch is correspondingly small ; and these conditions could not so 

rhus of the mammary gland, might be specially alluded to. Speaking of the 
operation, he says, — 

" The flaps, which were very large, had "been carefully laid down, strapped 
with isinglass plaster, and well tended. After death, which occurred in three 
weeks, from erysipelas and phlebitis, I cut off the edges of the wound with 
the subjacent parts, expecting to find the evidences of union by organized 
lymph, or, possibly, blood ; but neither existed ; and the state of the parts 
-cannot be better described than by saying that scarcely the least indication 
remained of either the place where the flap of skin was laid on the fascia, or 
the means by which they were united. It was not possible to distinguish the 
relation which these parts held to each other from that which naturally exists 
between subcutaneous fat and the fat beneath it. There was no unnatural 
adhesion ; but the subcutaneous fat which did lie over the mammary gland 
was now connected with the fascia over the pectoral muscle. The parts were 
altered in their relations, but not in their structure. I could find," con- 
tinues Mr. Paget, "small points of induration where, I suspect, ligatures 
had been tied, or where possibly some slight inflammation had been other- 
wise excited ; and one small abscess existed under the lower flap. But, with 
the most careful microscopic examination, I could discover no lymph or 
exudation corpuscles, and only a small quantity of what looked like the 
debris of such oil particles or corpuscles of blood as might have been between 
the cut surfaces when the flaps were laid down. In short," says Mr. Paget, 
11 this was union by first intention; it was immediate, at once in respect of 
the absence of any intermediate substance placed between the wounded sur- 
faces, and in respect of the speed with which it was accomplished." 



OPERATIONS UPON THE LIPS AND CHEEK. 963 

uniformly exist associated, if it was the manner of the paring ex- 
clusively that gave the notch, and not the contraction, as described. 

The nearer, then, the approach to a union by first intention we 
can make in hare-lip, the better for our success will be the result. 
But can we not get immediate union in full ? This would imply 
that we have artery to artery, vein to vein, nerve to nerve. Well, 
the artery is a prominent point of reference, and the relations of 
surrounding- parts are in perfect unison. If we can get the mouths 
of the two arteries together, will not all other vessels assume, by 
compulsion, inosculation ? We may try for this, at any rate ; such 
care will necessarily insure to us the very nicest approximation of 
parts, and, if what is termed immediate union cannot be obtained, 
we may at least secure to our patient, by such care, the smallest 
possible scar. To secure the most perfect union, a wound should 
never be approximated until all hemorrhage has ceased and the raw 
surface becomes glazed with a film of lymph. 

Fig. 301 represents a modification in the ordinary operation for 
simple hare-lip which the author has now performed many times, 
and always with the most satisfactory success. This operation, as 
is seen, differs from that shown in the preceding figure in having 

Fig. 301. 




the parings utilized in place of being cut away. Studying the dia- 
gram, it is seen that the parings, being commenced at the nasal 
septum, have been cut to the free border of the lip, from which, sup- 
ported by their attachment, they hang. From the septum to the 
apices of the flaps it is seen that raw surfaces approximate : the 
parts in this condition are now brought and retained in apposition, 



964 



ORAL DISEASES AND SURGERY. 



Fig. 302. 



the pendent portion being trimmed to that shape which considers the 
labial swell. This operation performed, a notch cannot result. 
A second modification on the basal operation is shown in Fig. 

302. Here, as is seen, one side 
of the break (the left) is most 
extensively pared, the section 
taking off quite a portion of the 
free border of the lip. Upon 
the opposite side, however, the 
paring is compensatory. Study 
of the section will exhibit that 
the flap of the right side restores 
the removed part on the left, af- 
fording, at the same time, com- 
plete continuity of the free border 
of the lip at the mesian line. 




Complications. — The first modification of the simple mesian cleft, 
which has been described as a type, is where the break is to the one 
side or other of the labial centre, this centre constituting one of the 
lateral boundaries. This character of cleft, particularly so far as 
the left side is concerned, is by far the most common form ; indeed, 
it is to be denominated the type proper of hare-lip. 

In operating on a case of single break, laterally related, as thus 
described, certain variations, as must be seen, are demanded. Em- 
ploying the ellipse, it is recognized that the labial prominence would 
necessarily be thrown out of that exact mesial position which is its 
place. The same defect would reside in uniform pendent parings. To 
meet the objections, using the ellipse, a modification, as practiced 
by Malgaigne, is employed. This surgeon makes the one side of a 
simple V-cut upon the outer flap ; upon the mesian is practiced the 
ellipse. The bringing together of two surfaces so related throws 
down, as is seen, the free border of the mesian flap. 

A modification on the operation of the French surgeon, suggested, 
I believe, by Dr. Richard Levis, consists in making a double Y on 
the mesian flap; entering the knife just below the nostril, a first inci- 
sion pares the flap ; a second now removes from this surface a small 
Y-shaped piece, having its apex looking toward the cheek. In bring- 
ing the parts together, which is done by inserting a pin at the apex 
of the second Y and passing it through the opposite flap, it is seen 
that the free border of the mesian flap is alike bulged downward. 




OPERATIONS UPON THE LIPS AND CHEEK. 965 

Better, however, than the operations either of Malgaigne or of Dr. 
Levis, is a modification on the operation shown in Fig. 301 ; this, 
however, being on a precisely similar principle, the paring from the 
mesian flap being to such extent heavier than its fellow, as shall 
place the desired prominence in its right position. 

Another variety in hare-lip, and the next most common, is that in 
which the break is double, — that is, the single break is divided into 
two parts by a teat which starts out from the apex of the cleft ; this 
teat is seldom more than half the width of the lip. Fig. 303, kindly 
furnished the author by Dr. Harrison Allen, being a case from his 
practice, exhibits very satisfactorily an 
example of the most simple of such • FlG - 303 - 

double breaks. A second is shown in 
Plate IX., Fig. 4. For the correction 
of this defect, various means are re- 
sorted to. Some surgeons cut out the 
teat, thus converting the double into a 
single break, making the basis cleft as 
described. Others, on the contrary, after 

paring all the four sides, tease and strain the centre piece or teat until 
they get it on a level with the rest of the lip. Both of these opera- 
tions are very objectionable. The first takes away an unnecessary 
amount of substance from the lip, thus giving a tense, stretched 
appearance to the part, while, from the second manipulation, the 
natural resiliency which belongs to most tissue compels a character 
of notch or central depression almost as unsightly as the original 
deformity. In this simple form of double hare-lip it will be found 
the most satisfactory operation to pare the lateral flaps in the form 
as shown in Fig. 301, while the centre teat should be pared into 
the Y-form, the base being to the septum narium ; all the parts will 
thus be found capable of a neat approximation, the teat doing its 
share more or less in filling up the break. The approximation is 
to be made in the mode described. 

A second form of double hare-lip is that in which the alveolar 
process is associated with the teat. This is termed complicated 
hare-lip. The portion of process projecting into the cleft is gen- 
erally an intermaxillary formation, and holds the germs or developed 
incisor teeth. The correction of this defect implies a somewhat 
formidable operation. The first step consists in separating well the 
lip from its reflection over the process, should attachment exist. 
Next the gum is separated thoroughly from the projecting bone, 



966 ORAL DISEASES AND SURGERY. 

which bone the third step in the operation removes down to the natu- 
ral curvature of the parts, this last being effected either by means 

of saw, chisel, or cutting forceps. For myself, I prefer the cutting- 
forceps; it is certainly a much more convenient instrument than the 
Hey's saw so commonly employed. A straight and a curved chisel 
should also always be at hand. If in this third step of the operation 
the anterior palatine artery be wounded, the resulting hemorrhage is 
easily controlled, either by taking up the vessel or by touching it 
with one of the astringents ; or, if neither of these means suffices 
for its accomplishment, the artery may be touched with a red-hot 
cauterant needle, or, better, it may be plugged with a point of pine 
stick. The bone removed, the flaps of gum may be laid back in the 
cavity, where they will remain sufficiently approximated without the 
employment of any sutures. The operation upon the lip may now be 
performed at once in any of the manners described ; or, if the force of 
the patient be too much exhausted, it maybe left for a future period. 
These are the two principal forms of double hare-lip. An appre- 
ciation of the operations required for their cure will enable the sur- 
geon to meet satisfactorily any modifications that may present on 
either of them ; and these modifications, it is to be suggested, are 
constantly occurring. Let us, for a single moment, refer to an un- 
complicated double hare-lip, where the centre piece, or teat, as it is 
called, might be found so large and square as fairly to divide the 
lip into three parts. Now, here the mesian line of the lip would be 
found in the centre piece ; it would therefore suggest itself to any 
one that either side of the cleft was to be treated as a separate hare- 
lip — that is, the whole manipulation might be done at the one sitting; 
but there would have to be symmetrical parings made of either cleft. 
In such a case, we have also to take into account the concavity 
made on either side of our fissure, as reference is had to the influ- 
ence exerted on the free margin of the lip ; for here of course we 
require no swell. Whether, again, in these really double cases, 
we would first operate on the one side. and. when this was cured, 
on the other, is a matter which is to be decided by the judgment of 
the operator. Many surgeons prefer to correct the whole deformity 
at once. If it should be decided to do this, the operation would only 
deviate from the principles laid down, as regard would be had to 
approximating the parts. If the centre piece be small, it will be 
found the most satisfactory practice to pass the pins, wire, or what- 
ever suture material is used, directly from one lateral flap, on through 
the centre piece, to and through the other, thus uniting all the parts 



OPERATIONS UPON THE LIPS AND CHEEK. 967 

together by a common suture. If, on the contrary, a centre piece is 
broad and well covered by skin, the greatest good is found in using 
two sets of ligatures. As regards the single or double operation, 
the author is influenced by the width of the middle piece, the tense- 
ness or laxity of the tissue of the lip, and the endurance and condi- 
tion of the patient. 

A modification of the double hare-lip is one in which there is a 
projection, into the cleft, of the incisor teeth ; the alveolar process 
itself being sufficiently normal to allow of non-interference with it. 
This modification is commonly met with in the adult alone, or at 
least after second dentition. The projection of the teeth is the 
natural result of the lack of external support from the labial defi- 
ciency ; the tongue has actually pushed them outwardly. This 
explanation will seem strange only to such as are unacquainted with 
the exceeding mobility of the dental organs under slight but con- 
tinued force. It is certainly the true cause of such projection. In 
a case of this kind, a preliminary operation is the removal of the 
teeth. If, now, six months be allowed to intervene before attempt- 
ing the operation on the lip, the alveoli of the extracted teeth will 
be found to have receded, through absorption, quite the eighth of an 
inch. The second operation is then to be done secundum artem. 
This waiting on the process of absorption will be found greatly to 
conduce to a successful result. 

A still better, though a more tedious, mode of correcting such a 
deformity is by first bringing the projecting teeth back to their 
normal place in the arch, through the agency of elastic ligatures. 
This is a perfectly feasible operation, and not at all difficult of per- 
formance. By such a preliminary procedure we not only get the 
teeth out of the way, but we save to the patient these valuable 
organs. To make and apply such a ligature, we have only to take 
a slip of common india-rubber and attach at each end a loop of silk. 
We next place these loops over certain of the molar teeth ; it is entirely 
immaterial which : the centre, or rubber part, is then stretched forward 
and laid over the labial faces of the teeth to be pulled back. It is 
astonishing how quickly and powerfully such a force will act upon 
the teeth. In two or three weeks, at most, the organs may be brought 
into their proper line. To secure them in situ, and prevent their being 
again pushed forward, we have only to keep them ligatured in any 
convenient manner until the operation on the lip is made, and union 
secured. 

Cleft of the lip, as previously remarked, is common to perhaps a 



968 ORAL DISEASES AND SURGERY. 

majority of the cases of cleft of the hard palate. It has always 
been deemed very important in these cases that an operation on the 
lip should be performed as early as possible ; it is thought to favor 
approximation in the bony cleft. In these cases the operation 
differs from that suited to any ordinary one only when there is pro- 
jection of one or both alveolar prominences into the break.* In 
such instances, if the projection be very marked — that is, so much 
so as to prevent the bringing together of the lips — we may perhaps 
be able to do nothing better than cut away the parts. This, how- 
ever, is always to be avoided where possible : first, because thus 
we destroy the germs of the teeth ; and, secondly, because, if by 
any means we can get union of the lip, the parts in their develop- 
ment will come mutually to accommodate themselves to each other. 
In such cases it is recommended by some authors that we endeavor to 
bend back these juttings of bone, turning them in toward the mesial 
line. Where this can be done, it answers a very admirable purpose. 
Still another mode — after the method suggested for the complete re- 
lief of this character of cleft — consists in the employment of the fronto- 
occipito-labial elastie sling. This sling is so applied that it pulls 
from the occiput upon the projecting process. It will certainly fulfill 
the indications ; but its employment is not unattended with trouble. 

Cases of double hare-lip not unfrequently occur where the centre 
slip is so associated with the septum of the nares as to make the 
parts seem as one: if there was not the loss of material from the lip, 
the septum would bear being described as in a state of hypertrophy. 
.Again, the lost part from the lip is sometimes found attached to the 
very tip of the nose, giving to the patient somewhat the appearance of 
laboring under lipoma. These, together with all the anomalies in this 
direction, are first to be studied, as regards their cure, from the artistic 
stand-point. The surgeon knows where and what he can afford to 
cut ; he judges what nature will do in the case ; it only remains for 
him to consider well his incisions, where he shall make them, and 
what is to be the artistic result, before the operation is attempted. 

A useful study is found in the examination of examples. If we 
familiarize ourselves with all kinds of cases, and if — what is commonly 
found more at command. — we represent the morbid anatomy in india- 
rubber, and thus devise and try experimental operations, we shall, I 
am sure, find the subject of hare-lip grow simple enough. 

Addenda. — In operating for hare-lip, always first dissect the lip 
well off from its attachment to the gum. 



* See Cleft Palate. 






OPERATIONS UPON THE LIPS AND CHEEK. 969 

In paring the fissures, the young surgeon is much more apt to 
remove too little than too much, 

In paring out the apex of the cleft, be sure to freshen perfectly 
the extreme point of such apex. This is oftentimes neglected ; and 
an ugly pucker is the result. 

The paring for hare-lip is, perhaps, best made on a wooden spatula. 

Few instruments are really required in this operation. A scalpel 
and forceps, together with such ligature material as it is designed to 
employ, will answer the purpose well enough. 

A mode of operating on the infant is for the surgeon to seat 
himself face to face with an assistant. The child being etherized, 
the surgeon lays its body over his own knees, the head being 
supported by the assistant. Upon the incision being made on one 
side, the assistant grasps the lip between the thumb and finger, 
compressing the coronary artery. When the artery of the opposite 
side is cut, he secures this. Both are steadily held until the oper- 
ator is ready to coaptate the wound. 

In operating on the adult, I think it will be found the most con- 
venient plan to stand behind the patient ; such a chair being used, 
and the head being placed in such position, as recommended in the 
operation of staphyloraphy. 

Another very convenient manner is to sit in front of the patient, 
the head being supported against the breast of an assistant. . 

When plaster is used to assist the ligatures, silk gauze and collo- 
dion are to be preferred ; this leaves the wound constantly exposed 
to inspection, and is a light and most effective dressing. 

STUDIES IN COMPLICATED HARE-LIP. 

Fig. 304 is a dissection showing the nature and character of the 
intermaxillary projection. Where such p 304 

bone interferes with the ability to obliterate 
the cleft, it is plainly seen that it may be 
cut away. 

Figs. 305, 306, 307, and 308, which are 
strictly true to cases constantly being met 
with, exhibit aspects of intermaxillary 
complication. Wherever such intermediate 
projections are found unyielding, and may 
not as soft tissue be utilized, the author 
pursues the practice of cutting the parts 
away: this converts the case at once into single hare-lip, with the 




970 



ORAL DISEASES AND SURGERY. 



complication, however, of a very great loss of substance from the 
centre of the lip ; this may not be helped ; and if the parts are found 



Fig. 305. 




Fig. 306. 




too widely apart to be brought together, as directed in the ordinary 
cases, the operator may be compelled to resort to the cheeks for the 
required material. (See Making Upper Lip.) 



Fig. 307. 




Fig. 308. 




Fig. 309, being from life, represents the appearance of a child 
operated on by the author at one of his late clinics. In this case 
complete cleft existed not only in the lip but in both hard and soft 
palates, while pendent from the nasal septum was a mass half car- 
tilage, half bone, which, as shown in the drawing, was the complete 
representation, in shape, of a door-knob. 

In examining this case, it will be seen that the removal of the 
pendent mass might be in a moment effected by section of the 



OPERATIONS UPON THE LIPS AND CHEEK. 971 

pedicle. This was done, exposing now fully the cleft in the lip> 
which, as is recognized, was very extensive. To make raw and 
bring the boundaries of this cleft in apposition was now the indica- 
tion. This was accomplished after the manner of utilizing the 

Fig. 309. 




parings; the strain on the pins, however, being very great, extra 
support was given by placing a roll on either side and dragging all 
the lateral aspect of the parts toward the mesial line by means of 
adhesive strips. 

In this case the strain on the pins necessitated their removal 
earlier than was desirable; but moderate union was found to have 
been secured at the free border of the lip, — that is, with the parings. 
Taking advantage of this, support was kept up by means of the 
extemporized Hainsby's compress, and after two weeks the cleft 
was found obliterated, having been filled up by granulation. 

This case is selected as an example, because it is an instance 
where nothing better might have been done than the operation 
practiced, the child not having force to endure a more complicated 
means of treatment. It was not desirable to have a cure by gran- 
ulation ; but it was better than taking risks overbalancing the good 
to be secured. 

Tig. 3, Plate IX., exhibits the manner of placing a pin. 

Fig. 5 exhibits three pins in place, the points being cut off, and 
the parts retained in apposition by means of the figure-of-8. 

Fig. 6 exhibits the dressing of a simple, uncomplicated double 
hare-lip. 

Pins. — Until very familiar with the operation, it is advised that 
in approximating flaps the ordinary steel or gold pin be used. Such 



972 



ORAL DISEASES AND SURGERY. 



means, while having the objections noticed, will yet be found of 
most ready and convenient application. 

In passing a pin, it is to be carried forward until within about 
three lines of the head. 

In casting the figure-of-8, no more strain is to be employed than 
suffices simply to hold the denuded surfaces in contact ; more than 
this is almost sure to result in strangulation of the compressed parts, 
and consequent ulceration marking the line of the pins. 

Pins are always to be removed as quickly as the parts are found 
sufficiently self-supporting, their presence interfering necessarily 
with the process of union. 

In withdrawing a pin, support is demanded by the lip. A rude 
removal is apt to tear asunder the delicate granulations. 

Fig. 310. 




Fig. 310 exhibits the twisted or hare-lip suture, together with 
the manner of making it. 



£k 












1 



: 



Plate I 



Fi 






Fi< 





CHAPTER XLVII. 

OPERATIONS UPON THE LIPS AND CHEEK. 

As the result of disease or accident, persons occasionally suffer 
from contraction of the orifice of the mouth, — a most unhappy con- 
dition, both as regards the appearance and the comfort of the 
individual. Such contractions are represented in Plate IX., Figs. 
1, 8, and 9. 

Dieffenbach, of Berlin, who interested himself very much in the 
surgery of the mouth, suggested and practiced for the relief of these 
deformities an operation, which, with occasional slight and unim- 
portant modifications, is the one still generally employed. 

Dieffenbach's operation is performed on the following principles ; 
Map out with pen and ink on the tissues such lines and angles as 
shall meet your approbation of what the proper mouth should be. 
These lines are, of course, to be in conjunction with the existing 
orifice or commissure, wherever or however situated, — that is, the 
relation of the existing orifice must be studied as it is to have 
association with the cuts you are to make. Thus, glancing at 
Fig. ?, we at once appreciate the necessity for enlarging the mouth 
by sections equilateral to the centre, as certainly it is apparent 
enough that only by such a form of incision — which I have caused 
to be represented by a line — could we secure the end at which we 
aim. Fig. 8, on the contrary, would demand an operation exclu- 
sively lateral ; for here the mouth at its right angle is as perfect as 
we could hope to make it. Fig. 9 presents us with a complication 
on these simple conditions. These complications might be multi- 
plied almost indefinitely; for who may say in what condition a 
wound or other injury shall leave a part ? At any rate, the surgeon 
is to be prepared to meet all kinds of modifications. These 
three figures give, however, as just an idea of the mechanico- 
surgical indications of such cases as any others that might be 
drawn. Figs, t and 8 are from life ; 9 is one made up to represent 

(9t3) 



974 ORAL DISEASES AND SURGERY. 

a not unlikely aspect.* It exhibits, as is seen, a combination of a 
cicatrix and hare-lip. In this last case is suggested of itself the 
necessity for a double operation. The mouth is to be made smaller 
before it would be at all proper to attempt making it larger. We 
must first perform a hare-lip operation. Imagine this done, and 
then further the condition in which such operation would leave the 
orifice. If we refer to the drawing, we see that the opening is now 
at what is properly the right angle of the mouth ; and an operation 
for the making of a proper commissure, if there was no hare- or 
cleft-lip, would be precisely the same lateral incision as that indi- 
cated in Case 8. But then it is to be remarked that, after the first 
operation was performed, the orifice would not be, as now, at the 
proper right angle. The bringing of the cleft together would pull 
it naturally toward the mesial line. Thus, then, it is made a cross 
between T and 8 ; it is not like 7, because it is not exactly in the 
mesial line, and it would not be like 8, because it has been drawn 
from the proper right angle toward the mesial line. Here, then, the 
complication has materially changed the indications of the principal 
operation. The incisions would have to be bilateral, but yet not 
equally so as reference is had to the false commissural centre, but 
only as reference would be made, say to the septum narium or any 
other fixed mesial line proper. The space between the central 
incisor teeth would be a good mesial centre to take. 

These features well considered, we take up a pair of sharp-pointed 
scissors, and, passing a finger of the left hand into the mouth, enter 
one blade of the scissors down through the tissues toward the 
finger, sparing alone in the puncture the mucous membrane; the 
blade is now pushed forward toward the mesial line, and the tissues 
incised, as indicated by the superior right lateral half of the ellipse 
represented by the line in Fig. 7. The scissors are now reintro- 
duced at the previous point of entrance, and the cut made on the 
inferior lip precisely as was done above. Next dissect out the 
triangular piece. Repeat these incisions on the opposite side. The 
next step considers the incision of the mucous membrane. This is 
done simply by dividing it down the centre to within two or three 
lines of the angle of the wound ; it is then to be brought over the 
cut surfaces and attached by means of the interrupted suture to 
the skin. 

* Fig. 9 is not correct to the text : add to it the defect in Fig. 1, and it will 
he right. 



OPERATIONS UPON THE LIPS AND CHEEK. 975 

This mode of re-establishing the orifice of the mouth is thought 
by many surgeons to be the best that can be employed. Prof. 
Smith, of the University, reports two cases operated on after this 
method, which resulted, he says, to his entire satisfaction. 

The late Prof. Mutter reports similar satisfactory results.* 

* Dr. Mutter's Case. — The patient was a daughter of a respectable practi- 
tioner of medicine residing in South Carolina, and, at the time the accident 
productive of the deformity occurred, was about eleven years of age ; of fine 
general health, though of a temperament strongly lymphatic. 

In the commencement of the winter of 1835, while at play with her com- 
panions, she was by some means or other thrust against a heated stove, by 
which her hands, arms, neck, and the lower part of her face were severely 
burned. 

Her wounds were treated in a most judicious manner by her father ; but, 
in spite of all his efforts, those about the mouth cicatrized with so much con- 
traction that the entrance into this cavity was almost obliterated. As soon 
as the tenderness of the part was somewhat diminished, he commenced a 
course of treatment calculated to restore this orifice to its natural size. He 
first began by introducing sponge tents, which were allowed fully to distend 
themselves ; but, after repeated attempts with them, by which he caused the 
child much suffering without materially benefiting her, they were abandoned. 

He then attempted to dilate it by first making an incision about six lines 
in length, extending from each angle of the mouth in an outward and nearly 
horizontal direction, and afterward introducing the tents to prevent the lips 
of the wound from uniting. This appeared at first to be productive of some 
good ; but in a short time they contracted and cicatrized, and the patient 
remained in as uncomfortable a condition as before. 

Finding himself foiled in both attempts, he determined to bring her to 
Philadelphia for the purpose of consultation. She was accordingly brought 
on, and became a patient of Professor Mutter, who says, " When I first saw 
her, nearly a year had elapsed since the occurrence of the accident. Her 
appearance at the time was very singular. Firm and dense cicatrices nearly 
surrounded the mouth, but were most marked on the lower lip and about the 
angles, while the orifice of this cavity was barely large enough to admit the 
point of the finger, and presented an oval form. The cicatrices of the incis- 
ions made by her father were also very apparent at each angle. Her general 
health was perfect ; and it was only on account of the deformity and difficulty 
of taking her food that the operation was requested. Her speech was not 
much affected, although some of the labial sounds were imperfectly pro- 
nounced. The lining membrane of the mouth was perfectly normal." 

" From the history of the case," says Prof. M., "I concluded it would be 
utterly useless to attempt a cure by the repetition of the measures already 
employed, and which are the only ones usually had recourse to. I therefore 
proposed the operation devised by Dieffenbach, and, her father consenting, 
it was accordingly performed on the 28th of the month of consultation. 

" The operation completed, a common roller bandage was applied, as in 



976 ORAL DISEASES AND SURGERY. 

A modification of the mode of Dieffenbach, which I would sug- 
gest, and which I am confident will yield still better results, is an 
association with these surgical means of a mechanical appliance. 

cases of fracture of the lower jaw, in order to prevent any derangement of 
the wounds. The patient was then placed in "bed, with her head elevated, 
and, as she had just before the operation eaten freely of some light food, 
ordered to take no nourishment of any kind until the next visit, and to be 
perfectly silent. 

" 29th. Passed a good night ; slept well ; no fever, and complains of no 
pain ; parts merely a little sore ; needles all in place ; writes that she is 
hungry. Ordered thin oat-meal gruel as diet, which, as well as her drink T 
is to be given with a small teaspoon. 

"30th. Quite as well as yesterday; everything in place; bowels costive ; 
ordered an injection of white soap and water ; diet as before. 

" 31st. Complains of stiffness in the wounds, but no pain ; dressing all 
secured ; injection had operated well ; pulse natural ; ordered chicken soup 
for diet. 

"Dec. 1st. The bandages were removed, and the first dressing commenced. 
The sutures, which had been closely bound down to the parts by blood, were 
carefully softened with warm water and cut away. As soon as they were 
removed, and the parts properly dried, the most gratifying exhibition of the 
success of the operation was afforded. On both sides, union between the 
everted mucous membrane and the margins of the wounds had taken place 
nearly throughout, and the new lips presented an appearance almost natural. 
Some of the needles were then removed ; but, as there appeared to be a 
feebleness in the adhesion at some points, the needles passing through them 
were allowed to remain, and a thread cast loosely around them. The bandage 
around the head was also reapplied. 

"2d. Second dressing, parts all firm and healthy ; the remaining needles 
were now removed, and the bandages only reapplied, which was done to 
prevent talking ; no pain in the part, and the patient in fine spirits. Ordered 
bowels to be opened with an injection, and the diet to be more nutritious, but 
still liquid. 

" Nothing remarkable occurred in the subsequent treatment ; all dressings 
were taken off on the 15th, and the child allowed to pursue her ordinary 
course of life. The mouth presented a very good appearance, though the lips- 
were somewhat thinner than natural, and there was some difficulty in bring- 
ing them in close contact, especially at the central portions." 

Mr. Liston reports a case of equal interest. Mrs. H., aged twenty-two,, 
was knocked down in a brawl, and a man jumped upon her, lacerating and 
bruising her cheek and mouth extensively, and fracturing her jaw. She 
went to St. Thomas's Hospital, where her jaw was put up and bandaged. 
These were not removed for some time ; and, when taken off, the wound on 
the right side of the mouth was found healed, and the cicatrix considerably 
contracted ; since then the contraction has continued somewhat, and now is 
so small that she can scarcely get any solid food to pass her lips. There is a 



OPERATIONS UPON THE LIPS AND CHEEK. 977 

After the operation, as described, has been performed, and time 
has been given for union of the reflected mucous membrane, let such 



large, dense, white cicatrix on the right side of the mouth, rather puckered, 
and sharp toward the angle of the mouth. An operation was performed on 
the 23d. Mr. Liston removed a triangular portion of the cicatrix on the right 
side of the mouth, dissecting it off the mucous memhrane, which was then 
divided to the extent of the external wound. Lint dipped in cold water was 
then laid over the surface to suppress the oozing of blood, which was by no 
means considerable. About five hours after the operation, all oozing having 
ceased, the mucous membrane was turned over the cut edge of the cicatrix, 
and united by three or four points of suture to the skin of the cheek ; by this 
means a mucous surface was secured to the newly-formed prolabium, and the 
gradual cicatrization and consequent contraction dispensed with. 

History of the case, from notes : 

24th. A little swelling around the wound ; not much pain. 

25th. The sutures were removed to-day. Adhesion appears to have taken 
place between the mucous membrane and skin. Water dressing to he applied 
to the lips. 

Nov. 1st. The water dressing has been continued; union between the mucous 
membrane and skin took place to a considerable extent by the first intention. 
The remaining parts are granulating favorably. The mouth is much improved 
in appearance and usefulness. 

4th. The lip nearly healed, only a small sore remaining in the lower lip. 
Red wash dressing to be applied to it. Discharged much relieved. 

A case operated on by the author at his clinic, which resulted entirely satis- 
factorily, will be found in the Eeports of Dr. De Forrest Willard. 

"The subjoined case illustrates a successful operation under circum- 
stances of unusual difficulty. The deformity was of old standing, and the 
parts had suffered from several outbreaks of disease and ulcerative action ;. 
the mouth and parts around had now been the seat for many months of lupoid 
ulceration, mixed with a syphilitic taint, which had caused, in the process of 
cicatrization, great condensation of the lips and cheeks generally, and adhe- 
sions between the cheek and the gum of the upper jaw. The mouth was- 
reduced to the smallest dimensions, and would absolutely not admit the point 
of the little finger ; there was also a hardened papillary growth on the lower 
lip The patient had not taken any solids for months, and had to use a kind, 
of little ramrod to introduce his food through the narrowed and immovable 
opening. His speech was necessarily imperfect, and any continued conversa- 
tion impracticable. The patient was thirty-five years of age, much broken, 
down in health and spirits, and urgently sought relief from the gradual 
narrowing of the orifice and from the ulceration which still existed. 

" He had suffered from exfoliations of the forehead and osteoscopic pains, 
and the tongue was painful from ulcerations, which could not be treated by 
any ordinary local stimulation. 

" Large doses of iodide of potassium were administered ; a tongue-bath of. 
black-wash, used twice daily, and good diet ordered. 

61 



978 ORAL DISEASES AND SURGERY. 

an appliance as is here figured (mouth-stretcher, it might be called) 
be prepared, and slip it between the lips. This stretcher represents 




a properly-shaped mouth ; the lips in the whole of their circumfer- 
ences are caught and held by the gutter of the apparatus, and thus 
not only is the healing influenced to a desired shape, but undue 
cicatricial contraction is prevented. 

" After five weeks the ulceration of the lips and mouth had much improved, 
and when the healing process had completed itself I adopted the following 
procedure in order to insure as much as possible against contraction. I 
passed a full-sized Chassaignac's drainage-tube through the cheek, about 
three-quarters of an inch from the angle of the contracted mouth, and re- 
tained the tube in this position, acting as an issue till cicatrization had taken 
place around, and a fistulous orifice, in fact, formed : this occupied about 
fourteen days in its production. I then from this point carried two incisions 
toward the mouth, and removed a rather wedge-shaped piece, its apex being 
at the fistulous opening produced. This was followed by a satisfactory result ; 
the parts gradually healed, but some contraction nevertheless occurred to 
about one-half. "When this side was tolerably healed I adopted a similar 
proceeding at the other, but I took care to increase the distance from the 
angle of the mouth ; after fourteen days, when I found the tubing had suffi- 
ciently established a fistula, I took away also a wedge-shaped piece, as at the 
other side, and adopted every precaution to prevent further narrowing. I 
gained on this side more than half the distance. The mobility of the jaws 
was perfect ; the patient had lost many of the teeth by ulceration of the alveoli, 
and the integument over the chin was drawn as tightly as it is possible to 
conceive. 

" The comparative illustrations of the condition before and after operation 
will show the great narrowing that had taken place, combined with increased 
density, almost of a cartilaginous firmness, and the improvement gained. 

"The repair of the general health, and the rapidity with which he regained 
his weight and strength, were remarkable in this patient; he felt so strong 
shortly after being operated on as to leave hospital and go to work. 

" The use of the tubing, and the formation of a fistulous point to act from 
and insure a permanent angle to the lips, I found most satisfactory as the main 
cause of a perfect result to the patient ; the tendency to contract and curtail 
the natural opening was most persistent." — Mr. Morrison, F.R. C.S.I. 



OPERATIONS UPON THE LIPS AND CHEEK. 979 

If it is objected that such an instrument would look ungainly in 
the mouth, I have only to answer that after the first week or two 
there would exist no occasion for its constant wearing; it might be 
entirely dispensed with during the day and be worn only at night. 
Such use of it, however, should be continued at least six months, if 
we would have the cure perfect. 

An advantage that would be yielded by such an appliance to a 
bungling operator would be that it would naturally correct any im- 
perfection in his operation ; the character of the apparatus compel- 
ling the regular healing of the wound. Indeed, I am not sure but 
that in this way a proper mouth might be made if the strictly sur- 
gical part of the manipulation consisted only in a simple incision to 
enlarge the parts to a proper capacity ; for in the operation it cannot 
be said that the reflection of the mucous membrane is an absolute 
necessity : whether this membrane should be carried over the cut 
surface or not, we would very soon have it clothed with such tissue, 
or at least with that which would be found sufficiently analogous to 
fairly represent it. Dr. Mutter, in remarking on the philosophy of 
this operation, suggests that the annals of modern surgery hardly 
afford an example of greater ingenuity than the procedure of Dieffen- 
bach. M The great difficulty," he truly remarks, " in all these cases 
arises from the constant tendency to contraction manifested by the 
cicatrix, which occasionally goes on to such an extent that the orifice 
of the mouth is almost closed. At the first examination of such a 
deformity, the remedy which seems to promise most success," says 
Dr. M., u is mechanical dilatation. Unfortunately, this is productive 
of but temporary relief, and has never, I believe, effected a perma- 
nent cure. Next to this method comes incision of the commissures. 
We might naturally expect such a course to be sufficient to effect 
the ends desired ; and in all probability this would be the case, could 
we by any means prevent reunion of the edges of our incisions. 
But this, it would appear from statements of the best authorities, 
has hitherto been impossible ; for, notwithstanding the introduction 
of tents, leaves of sheet-lead, cerate cloth, etc. between the lips of 
the wounds, adhesions, more or less complete, are sure to take place." 

The instrument which I suggest will, I think, meet indications 
which the appliances heretofore used have not been able to meet. 
A tent, or cerate cloth, or strip of easily yielding sheet-lead might 
not resist the great contractile force existing in these conditions; 
something fixed and immovable is required. One would not be 
willing to trust to a less resisting body than the catheter, after 



980 ORAL DISEASES AND SURGERY. 

urethral section. It might be asked, " What need of such appliances, 
if Dieffenbach's operation will effect a cure?" Unfortunately, Dieffen- 
bach's manipulations cannot in all cases be carried out. If the 
mucous membrane, for example, participates in the lesion, the opera- 
tion cannot be successfully performed. Or who can say that flaps 
of mucous membrane, however nicely approximated with the skin, 
will unite ? There are several things which may come between the 
surgeon and success. There are, at least, cases which Dieffenbach's 
nice operation will not cure. 

A preliminary operation, having the object of obviating the tend- 
ency to closure of the mouth, consists in first passing through the 
tissues, at the proposed sites of the angles of the lips, setons of deli- 
cate india-rubber tubing. These are to remain in place until the 
orifices are cicatrized, precisely as in the case of the bored ear. No 
trouble after this is experienced in preserving the mouth as formed. 

Studies. — Plastic operations about the lips are embraced under 
the general name of cheiloplasty ; those upon the cheeks are termed 
genioplastic. 

The necessity for such operations arises from various causes, not 
the least frequent of which are sections made by the knife of the 
surgeon. Reference to Plate X. exhibits five cases ; the first result- 
ing from salivation, the second from an ulcer, the third, fourth, and 
fifth due to operations for the removal of cancer. 

The first of these (Fig. 1) is described as having been a shock- 
ing deformity. The operation for its relief was performed by Prof. 
Mutter, the practice being as follows. Having first extracted the use- 
less teeth of the upper jaw, which would have prevented the proper 
adjustment of the flaps, or induced their ulceration, the edges of the 
ulcer were freshened, and the integuments detached from the side of 
the jaw. Two incisions, one above and one below the ulcer, as 
seen in the figure, were made, so as to form four flaps. These were 
now allowed to fall together, and were united in the line of the teeth 
as far forward as the natural angle of the mouth. The result was 
entirely satisfactory. 

In studying this case, the reader will remark that while the mode 
of section, or making the flaps, most happily meets the indications 
so far as filling up the seat of the original lost tissue is concerned, 
yet this is only done by making two other defects, one above, the 
other below. Such defects, however, prove, in healthy tissue, of no 
great consequence ; granulations, quickly springing from the whole 



OPERATIONS UPON THE LIPS AND CHEEK. 981 

circumference of such wounds, supply the lost tissue : indeed, in my 
own experience I have found, as a rule, that the tendency in these 
fresh parts is to so rapid a granulation and cicatrization that fre- 
quently the line of the artificial union is torn apart. 

Fig. 1 may be studied from another stand-point. In a case 
operated on by myself, very similar to the drawing, where the neigh- 
boring tissues were loose and free in character, I succeeded in effect- 
ing an admirable cure by simply dissecting the parts from the bone, 
freshening the edges, and uniting them by the ordinary hare-lip pin, 
supporting the whole by straps of adhesive plaster passed from be- 
neath the jaw to the side of the head : the parts at first looked very 
much stretched, but soon accommodated themselves. 

Still another mode of performing such operations is after the 
manner of Taliacotius. Freshening the edges as before, map out, 
by means of a piece of card-paper, the size of a flap required to fill 
up the gap ; next lay this upon the arm, and, dissecting from the 
integuments its size, supported by a pedicle, fix it in the break by 
means of stitches of the interrupted suture. To do this, the arm 
is to be brought over the head, and thus supported until union is 
secured, when the pedicle is to be detached, and the parts trimmed 
to suit. 

Subfig. 2, constituting a second study, represents an operation 
performed by Mott for the relief of an anchylosis of the jaw depend- 
ent on cicatrization of the mouth with the restoration of a part of 
the cheek. 1, exhibits cicatrix arising from an ulcer. This was 
entirely excised, leaving an opening in the cheek. 2, tongue-shaped 
flap cut to fill up the opening by being rotated upon its base. 

Subfig. 3 represents an operation performed by Prof. Pancoast for 
the removal of an extensive cancer, and the formation of a new 
lower lip. The cancer is shown as circumscribed by a curvilinear 
cut. A vertical incision in the median line of the chin extended 
from the curvilinear cut nearly to the os hyoides, and another, 
which was horizontal and parallel to the base of the lower jaw, 
formed four flaps. The angles of the flaps being removed, the upper 
flaps (1, 2) were raised to the proper level, and united by the twisted 
suture on the median line, when the lower flaps (3, 4) were also 
united on the median line so as to cover the front of the chin. 

Subfig. 4 represents a similar case, treated by the operation of 
Chopart. The lines show the idea of the incisions. 2, 4, circum- 
scribe the disease. 1, 5, 3, 6, show vertical cuts. The diseased 
part, all above 2, 4, being removed, the integuments are loosened 



982 ORAL DISEASES AND SURGERY. 

from the lower jaw, and simply lifted up, being retained in the new 
position by hare-lip pins, or other convenient form of suture. This 
operation occasionally answers very well ; in certain instances, how- 
ever, where, for example, it has been necessary to stretch the parts, 
much cicatricial evulsion is apt to occur. 

Subfig. 5 represents the same position of the disease, treated after 
the manner of Lallemand. 1, the remaining portion of the lip, 
which is to be drawn over to the angle of the mouth at 2. A flap, 
formed of the integuments of the neck, having been dissected off, is 
shown as being partially rotated on its base, and about to be carried 
up to cover the deficiency. The wound on the neck may either be 
approximated at its edges, or left to heal by granulation. 

In epithelial cancers quite as large as those represented in Figs. 
3 and 4, I have succeeded in securing the most perfect cures by 
practicing the operation of Malgaigne. This consists in removing 
the diseased mass by a simple Y-incision ; the angles of the mouth 
are next enlarged by horizontal cuts, and the Y drawn together and 
united in the middle line of the face. In my own cases I have 
always placed a pin at each corner of the mouth ; as the result of 
this, some little puckering is produced, but, in return, it eases the 
strain on the middle Hue, and itself disappears after a very few 
months.* 

* The lower lip, from its conspicuousness, its utility in articulation, and also 
in the prevention of an involuntary and incessant flow of saliva, forms a very 
important portion of the face. Unfortunately, it is exceedingly prone to 
diseases of various kinds, especially tumors and ulcers, requiring for their 
relief the removal of the whole, or a portion, of the organ involved. It 
would be worse than useless to enter into a description of all the operations 
that have been devised to remedy its loss, but a brief sketch of the most novel 
and important may prove useful and interesting to those not familiar with 
this department of plastic surgery. 

Choparts Operation. — This operation consists in making, on each side of 
the diseased tissue, a perpendicular incision, extending from the margin of 
the lip to a point below the base of the lower jaw Dissecting up the flap 
inclosed between the incisions, he carefully removed from its upper mar- 
gin all the affected tissue, either by a transverse or a curvilinear cut. Then, 
pulling upon what remained of the flap, he brought its upper edge to the level 
of the margin of the natural lip, and there retained it by suture, straps, and 
placing the head of the patient in such a manner as to prevent all strain upon 
the part. This method, Dr. Mutter remarks, though apparently simple and 
easy of execution, does not generally answer, in consequence of the subse- 
quent contraction of the tissue. 

Horn or Roonhuysen's Operation. — If the part to be removed be small, the 



OPERATIONS UPON THE LIPS AND CHEEK. 983 

Fig. 312 exhibits conditions met with almost every day. Such 
ulcerations, being esteemed of cancerous signification, are commonly 

Fig. 312. 




treated by excision. Taking as example the two shown in the dia- 
gram, the manner of removal is portrayed in the circumscribing lines. 

common Y-shaped incision is sufficient, and the parts may be brought together 
as in the operation for hare-lip ; but where the mass is large, this process is 
sure to diminish the orifice of the mouth, and thus give rise to deformity and 
inconvenience. To obviate all this difficulty, it was proposed by Horn to de- 
tach the adjacent parts by free dissection from the maxillary bones, which 
would of course afford more material for the lip. The objection to this 
method is, that in many cases the orifice of the mouth is rendered so small as 
to be almost useless, besides presenting great deformity. 

Operation of Dupuytren — This, in ordinary cases, was nothing more than 
cutting away by a semi-elliptical incision all the diseased tissue. Granula- 
tions spring up from the margin of the healthy skin, occupy in part the place 
of the original lip, and conceal to a certain extent the deformity. It is only 
in mild cases, however, that such apneasure could succeed. 

Celsian Operation. — Having carefully removed the diseased part by a V- 
shaped incision, proposed to divide the tissue remaining horizontally, carrying 
the cuts as far into the cheek on each side as might be deemed necessary, after 
the manner of Horn ; but, in order to take off the strain from the flaps, he 
made a semilunar incision in the cheek, just beyond the base of each. This 
enabled him to bring the parts together without difficulty ; and the only ob- 
jection to this operation is the danger of wounding the larger vessels, nerves, 
and ducts of the cheek, in making the semilunar incisions. 

Operation of M. Serves. — If the disease, as is sometimes the case, is con- 
fined to the integuments and subjacent muscles, leaving the mucous lining of 
the lip sound, Serres cuts away only the affected part, and then turns the 
mucous membrane over the margin of what is subsequently to form the lip. 
A few stitches are sufficient to hold it in place, and, as union by the first in- 
tention usually occurs, a very natural and useful organ may thus be made. 



984 ORAL DISEASES AND SURGERY. 

The after-treatment consists simply in approximating the parts by 
the use of the pin and figure-of-8 ; adhesive strips being used, or not, 
as mav be found indicated. 



This method, however, will only answer in cases of superficial and recent 
disease. 

Operation of T. W. Roux. — After removing the affected tissues, and form- 
ing suitable flaps of the adjacent parts, M. Roux takes away with the saw or 
cutting instruments the prominent centre of the maxillary bones, so as to 
make room for the proper and easy adjustment of the integuments intended 
to replace the organ destroyed. This operation is barbarous, because unneces- 
sarily severe. 

Operation of P. Roux — Professor Roux, determined to surpass his name- 
sake, saws out an inch or more of the bone, and then, by drawing the lateral 
flaps toward each other, diminishes the breadth of that part of the face in- 
volved in the disease. Then, detaching the flaps, he draws them across the 
opening in the bone, and the sutures which hold the soft parts are generally 
sufficient to hold the bones in their proper places. 

Operation of Mr. Morgan. — This consists in first removing the entire lip 
by a semilunar incision, the concavity of which is uppermost ; and second, in 
making an incision also curvilinear and parallel to, and about an inch or 
more below, the first. The skin included between the two is then carefully 
detached, except at its extremities, and lifted into the place occupied by the 
diseased lip. 

Operation of M. Blasms. — M. Blasius has performed a very simple opera- 
tion when the tumor was large ; and, according to his statement, with decided 
success. After removing the diseased mass by a common V-shape incision, 
he next divided the integuments along the base of the lower jaw by two in- 
cisions, which commenced at the entering angle of the V, and extended an 
inch or more in the direction specified. Lifting the flaps, he made them 
occupy the place of the original lips. 

Operation of Dieffenbach. — This surgeon has recommended an operation ap- 
parently hazardous and severe. 

" Having pared away the useless remains of the former diseased lip, or 
separated the cicatrized margin, a horizontal incision, about two inches long, 
is carried from either angle of the mouth outwards, through the cheeks, so 
as to throw the mouth widely open. The length of these incisions must be 
regulated according to the width of the mouth ; or, as a general rule, the 
combined incisions must somewhat exceed in length the breadth of the upper 
lip. From the outer point of each of these, another incision is next carried 
obliquely downwards and toward the median line ; the section in this case 
likewise extending through the whole thickness of the cheek. Thus by means 
of the first operation for paring the cicatrix, and by the succeeding horizontal 
and vertical incision, a flap will be prepared on either side to replace the de- 
fective lip; this flap is of a quadrangular form, and maintains a connection 
of more than one inch wide with the soft parts covering the tissue of the 



OPERATIONS UPON THE LIPS AND CHEEK. 985 

Fig. 313 exhibits disease involving the entire lower lip, and necessi- 
tating its removal. To accomplish the necessary end, namely, to 



Fig. 813. 





remove the disease and restore the lip, various means are employed. 
(See foot-note.) On diagram 313 are shown the outlines of an opera- 
tion known as Serres's. In this mode it is seen that the tissues of 



lower jaw. It may be useful further to separate the mucous membrane at its 
attachment to the gums, to allow of the more ready traction of the flaps." 

The severe injury inflicted on the facial nerve, the large arteries and veins, 
and possibly the parotid duct, has rendered this operation anything but 
popular. 

Operation of IAston. — This consists in first removing the diseased mass by 
a horizontal and two perpendicular cuts, or by one curvilinear in shape ; 
and, second, in detaching a flap from the chin and neck, twisting it on its 
pedicle, placing it in the seat of the original lip, and there retaining it by 
suture. After adhesion has taken place, the pedicle is divided, and a wedge- 
shape piece removed so as to allow the flap to be laid down smoothly. This 
method, it is obvious, is frequently applied to the restoration of other parts, 
and will answer here exceedingly well in many cases. Dr. Mutter, however, 
prefers the following operation, " as there is less scar, and less risk of slough- 
ing of the flaps." 

Dr. Matter's Operation. — Having first removed the diseased mass by a semi- 
elliptical incision, two slightly curved incisions are carried from the centre 
of this line, downwards and outwards, to the base of the inferior maxillary 
bone. Then, from the terminal extremities of these incisions, two others are 
carried upwards and outwards along the base of the lower jaw until they 
reach a point opposite the initial and terminal points of the original semi- 
lunar incision. Two quadrangular flaps are thus marked out, and immedi- 
ately detached from the subjacent bones. These flaps are then raised and 
placed in the position originally occupied by the lower lip, and then united to 
each other at the median line, and also by their lower thirds to the triangular 
piece of integument (as between the two lines which started from the centre 
of the semi-elliptical incision), by means of the twisted suture. By the ele- 
vation of these flaps, a raw surface is left on each side to heal by the model- 
ing process or by granulation. — Mutter. 



986 



ORAL DISEASES AND SURGERY. 



the cheeks are utilized. Fig. 314 shows the disease removed and 
the wounds dressed. A marked objection to this operation is in- 
ability to gain such character of lower lip as shall control the direc- 
tion of the saliva, or permit of true and full approximation with the 
superior lip. In looking at the new lip, the reader is to observe the 
manner adopted of covering the same surface of the free border by 
stitching to the skin the mucous membrane. 

Fig. 315 exhibits a lower lip removed, and lines of incision prac- 
ticed by Mutter for the restoration of the lost part from the chin. 



Fig. 315. 



Fig. 316. 




Fig. 316 shows the flaps dissected and raised into place; the tri- 
angular spaces being left to heal by granulation. 

A modification made by the author on the sections of Mutter — 
cuts of which are shown in the clinical reports of Dr. Willard, pub- 
lished in the Medical and Surgical Reporter — consists in carrying 
the vertical lines beneath the jaw, so that the flaps when put in place 
show but the single central line upon the face. By this modification 
not only are observable scars avoided, but the lip is not apt to be 
shortened by the cicatrization : indeed, it is possible by such means 
of operating to obliterate the triangular breaks left in the operation 
shown, the yielding integuments of the neck being made to close 
the breaks. 

The transplantation of particles of skin, now an accepted opera- 
tion, may be practiced in the Mutter operation : this consists in 
snipping from sound parts small pieces of skin, and by careful appli- 
cation uniting them with the uncovered surface of the triangles. 

Fig. 317 exhibits an operation as practiced by the author for 
the removal and restoration of parts of both the upper and lower 
lips. 

At the angle of the mouth is seen the disease designed to be 
removed, circumscribed by lines which fully include it ; all tissues 
within these lines are removed. Commencing now at the angle of 
the wound in the mesial line, an incision is carried downward be- 



OPERATIONS UPON THE LIPS AND CHEEK. 987 

neath the jaw, and outwardly — as shown in the diagram — as far as 
the line of the facial artery ; this flap being next dissected from its 
base is lifted until it meets the free border of the natural half of the 







lip ; to this it is pinned. The angle seen back of the mesial incision 
will be recognized as receiving accommodation in the second angle 
in the upper lip ; this relationship limits the size of the commissure 
upon the side, which limitation, however, is to be corrected by a 
subsequent operation practiced after the manner of Dieffenbach. 

Remedy for disease thus situated is of frequent necessity. The 
operation shown is one that may be practiced with entire satisfac- 
tion. 

Fig. 318 exhibits lines of section demanded for the restoration of a 
lost upper lip. The case here shown, being from life, represents a 



988 



ORAL DISEASES AND SURGERY. 



gentleman for whom only a few weeks back the author found himself 
compelled to remove the upper lip, within the inferior lines shown, 
for relief from epithelial ulceration. Imagining the lip away, the 
reader will perceive that lateral flaps dissected from the cheek, as 

Fig. 318. 




shown in the diagram, must admit necessarily of being brought 
down and stitched together in the place of the lost part. 

Fig. 319, demonstrative of the same operation, exhibits the face 
of a patient when first presenting for treatment. 

Fig. 320 exhibits the appearance'of the face immediately after 
the completion of an operation for a new lip, practiced precisely as 
shown by the lines marked upon the face of Fig. 318. The tri- 
angular space, left necessarily on each cheek, as must be appre- 
ciated by a study of the drawing, on the left side is shown obliterated 
by compelling the cheek to override the space. On the right 
side the space has been allowed to remain. The artist, however, 
should have represented the ulcer by a dark rather than by a light 
surface. 



OPERATIONS UPON TEE LIPS AND CHEEK. 989 



The lady represented in Fig. 321 applied to the author three 
years back for relief from the deformity exhibited, the irregularity 

Fig. 319. Fig. 320. 




of features being dependent upon injury done the facial nerve in an 
inflammation and necrosis of the temporal bone from accident met 

Fig. 321. 




with in childhood. Paralysis was complete; not the slightest power 
existed in the muscles of the affected side. 



990 ORAL DISEASES AND SURGERY. 

The desire of the patient was for a symmetrical mouth and face ; 
the question was, the accomplishment of such an end. 

Treatment. — A case of this kind treated by any of the various 
means of nerve-stimulation is, of course, a consideration not involved. 
What is done can only be from the mechanical stand-point. The 
indications were threefold : 

1st. To reduce the flabby redundancy of the paralyzed cheek. 

2d. To give comeliness and regularity to the mouth. 

3d. To antagonize the muscular action (when in play) of the 
vital side. 

In this case these indications were attempted to be met by means 
as follows : A study was made of the cheek, and what was deemed 

Fig. 322. 




to be the redundant tissue was included in an ellipse drawn with a 
lead-pencil, one of the apices being at the middle of the nose, the 
other at the angle of the lower jaw, — such direction of the ellipse 
being with a purpose of raising the angle of the mouth. Satisfied 
that such removal would be found rightly placed to meet the two 
first indications, the part was cut out. In the operation the facial 
artery was the only vessel which needed a ligature, and even this 
ejected no more blood than does an ordinary coronary. 

To bring the parts together, three hare-lip pins were used, and 



OPERATIONS UPON THE LIPS AND CHEEK. 991 

agreeably to my surprise, so direct and immediate was the union 
that it was found permissible to dispense with two of them on the 
following day; the third, the middle one, was left in until the fourth 
day; but this, not seemingly from any necessity. The ligature, a 
strand of ordinary silk, remained firm for three weeks, and was 
finally taken away only by the use of a traction quite as great, I 
should think, as would have sufficed for its removal the moment 
after it was placed about the vessel. 

The result of this procedure is exhibited in Fig. 322. With the 
features in a state of rest, nothing more, it would seem, could be 
desired. 

The third indication, however, showed itself a most important one. 
Emotion of the face altered this mechanical harmony of the parts, 
and exhibited the non-vitality of the side operated upon ; that is 
to say, in laughter, for example, the superior and lateral levators 
would pull up the well angle, with no corresponding action on the 
diseased side. This was, of course, a matter which had been origi- 
nally considered. The indication was met with remarkable success, 
as follows : A piece of rubber tubing four inches long, possessed of 
an elastic power adapted to the requirements of the case, was at- 
tached by one of its ends to a hair-pin (the ordinary pin used by 
ladies in dressing the hair). To its other end was united a piece of 
strong, but delicate, gill-net string, and this, in turn, was connected 
with a small strip of flesh-colored court-plaster. 

The application of this piece of mechanism — an artificial muscle, 
let us call it — was made as follows : The plaster was softened and 
applied to the dead side of the face, as far back upon the cheek as 
would answer the purpose. When fixed, the lady, standing before 
her glass, would excite the displacing muscles into play, and antago- 
nize them by drawing slightly backward the dead side with the 
artificial muscle, and fix it in such required tension by the pin fixed 
into one of the coils of her hair, the rubber lying entirely concealed 
by such coil. When applied, only the plaster could be seen, the 
string being hidden by the hair. 

This rubber muscle answered its purpose admirably. The fear 
that the plaster would irritate, and perhaps ulcerate, the skin, seems 
to have been without foundation. At any rate, this held good for 
six months of use, which was as long as I was able to have over- 
sight of the case, the lady living in a distant city. Should, however, 
this accident have supervened, it was evident that, after a very few 
days of experience, a habit might soon be attained of accomplishing 



992 



ORAL DISEASES AND SURGERY. 



Fig. 323. 



the same object by the use of the fingers applied in such manner as 
not to elicit attention. 

This operation, the only one of the kind I have performed, has 
given results which I think will warrant its repetition. 

Fig. 323 exhibits an operation practiced by the author for the 
relief of an epithelial ulceration involving the full lower eyelid and 

a limited portion of the upper. The 
study of this operation illustrates a class 
in this direction. First, as seen in the 
diagram, the diseased structure is fully 
removed through incision associated 
with the uninvolved surrounding parts. 
Second, the hemorrhage being entirely 
controlled, a flap to replace the lost part 
was made, as shown in the inferior 
lines ; this flap being raised was carried 
upward, the convex portion being as- 
sociated with the concave break re- 
sulting from the section of the upper 
lid, — the slightly concave portion repre- 
senting the superior line of the lower 
lid. The triangular portion, seen in 
the diagram to exist at the side of the 
ala between the two incisions, was 
next dissected from its apex toward 
its base, and being dissected below what, in the diagram, is seen to 
be the inferior flap, was thus brought into relation with healthier 
influences, while a similar good was secured for the new eyelid in 
making it of tissue which had not been in immediate juxtaposition 
with the diseased part removed. 

In this particular operation no trouble was found in completely 

filling the gap made by the dissection, the loose tissue of the neck 

and side of the face being found amply sufficient to meet the demands. 

In studying the incisions here practiced, the practitioner will find 

all required hints for the various transpositions demanded. 




Burns. — Plastic operations practiced for the relief of cicatricial 
deformities must always be of special signification. Of such cica- 
trices there are of course an endless variety, and it may only be 
that each case shall command a special operation. 

Cicatricial tissue, always the result of suppurative inflammatory 



OPERATIONS UPON THE LIPS AND CHEEK. 993 

action, is a species of imperfect fibrous formation, dull white in color, 
hard, its fibres running in every direction and possessed of a con- 
tractility which, in many instances, requires years for its exhaustion. 
In vital force this structure is of low organization, peculiarly sus- 
ceptible to degenerating influences, rarely, if ever, developing to full 
likeness with its associated parts. 

The surgeon in treating a cicatrix will find himself wisely influ- 
enced in heeding the maxims of Dupuytren: 

" 1. Never attempt the correction of a deformity until months, and 
in many instances years, have passed after its production. 

" 2. Never operate unless certain of obtaining a larger cicatrix than 
that which is wished to be removed. 

" 3. Be certain that the operation can restore the parts to their 
shape." 

Dermoplasty, as this operation is called, is never to be undertaken 
without full consideration of the shock to be entailed by the cutting 
and suppuration, and the ability of the patient to endure such shock 
(see page 601). In removing a cicatrix, let Fig. 323 exhibit an 
example ; it is to be recognized that not only may a prolonged dis- 
section be necessitated, but the cutting is not at all unlikely to be of 
the most hazardous nature, requiring on the part of the surgeon 
not only a most accurate knowledge of the anatomy of the parts in- 
volved, but also a patience and a manipulative skill which are by no 
means a common possession. 

A secondary danger associated with these operations lies in the 
supervention of erysipelas, a contingency to be guarded against by 
that preliminary attention which has taken into consideration every 
functional irregularity which can have a tendency to lower the 
resistive force of the individual locally or at large.* 

A flap is always to be at least from a quarter to a third larger than 
the cicatrix to be replaced ; such increased size will be found necessary 
to counterbalance the shrinkage. 

A flap is always to be taken from the nearest healthy neighboring 
part. It is to have the widest pedicle the circumstances of the case 
will permit, and is not to be laid in its new situation until all 
hemorrhage has been fully suppressed and both flap and base are 
found covered with a film of plasm. 

In fixing a flap, unnecessary stitches are to be avoided, while com- 

* Erysipelas would seem to be a parasitic disease ; the fungi finding habitat 
in a part incapable of self-defense or resistance. 

62 



■H 



994 ORAL DISEASES AND SURGERY.. 

pression of the most gentle nature is to be used in holding the parts 
in apposition. 

No dressing except of the simplest character is to be used after 
an operation ; the surgeon is to take it for granted that no complica- 
tion will arise and that the union is to be immediate and full : should, 
however, such results not accrue, then indications are to be met as 
they may arise. 

Concerning the wound left by the transfer of the flap, it is best 
treated by the endeavor to close it by the overdrawing of neighbor- 
ing parts ; in large wounds, however, where this practice may not 
avail, the process of skin-grafting is to be had recourse to ; this, 
while not so reliable as is to be desired, serves at times a most 
satisfactory end. 

As studies in this direction of surgery, see foot-note.* 

* " Miss Mary S., aged twenty, daughter of the Hon. William S., of Ohio, 
canie to Wheeling, in the spring of 1848, to obtain relief from the effects of a 
very severe burn, which she had received fifteen years before. The burn 
was principally confined to the neck and lower part of the face, and its cica- 
trix produced a deformity of the most dreadful character. Her head was 
drawn downward and forward, the chin was confined within an inch of the 
sternum, the under lip was so pulled down that the mucous membrane of the 
left side came far below the chin, the under jaw was bowed slightly down- 
ward, and elongated, particularly its upper portion, which made it project 
about one inch and three-eighths beyond the upper jaw. In front there was 
scarcely any appearance of either chin or neck. She was unable to turn her 
head to either side ; the cheeks and upper lip were dragged considerably 
downward ; she could not close her eyelids ; she could not close her jaws but 
for an instant, and then only by bowing her head forward. She could not 
retain her saliva for a single instant ; and, as might be expected, her articula- 
tion was very indistinct. 

'• She had been taken to the city of !N"ew York, some years before, for the 
purpose of being relieved from this deformity, and was placed under the care 
of two of the most distinguished surgeons in that city, who performed an 
operation by dissecting up the cicatrix on the neck, then raising the head 
and sliding up the cicatrix from its original position, leaving a raw surface 
below to heal up by granulation. I need scarcely add that the operation was 
entirely unsuccessful. 

" After a careful observation of the case, it became evident that such a 
complicated deformity could be best remedied by performing three separate 
operations, — one upon the jaw, another upon the neck, and a third upon the 
under lip. 

" To remove the projection of the under jaw seemed to require the first 
attention. Unless that could be done, the other operations, however suc- 
cessful, would add but little, if any, to the personal appearance of the patient. 



OPERATIONS UPON THE LIPS AND CHEEK. 995 

This lengthening of the jaw had taken place entirely between the cuspidatus 
and first bicuspid tooth of the right side, and between the first and second 
bicuspids of the left. By the elongation, the teeth just described were sepa- 
rated on both sides about three- fourths of an inch. 

"To saw out the upper edge of these elongated portions of the jaw, and 
then to divide that part of the jaw in front of the spaces thus made, by sawing 
it through in a horizontal manner, so as to permit the upper and detached 
portion to be set back in its original position, appeared to be the only possible 
way of remedying the deformity. This plan I therefore adopted, and per- 
formed the operation on the 12th day of June, in the manner now to be 
described. 

" The operation was commenced by sawing out, in a Y-shape, the elongated 
portions, together with the first bicuspid on the left side, each section extend- 
ing about three-fourths of the way through the jaw. I then introduced a 
bistoury at the lower point of the space from which the section was removed 
on the right side, and pushed it through the soft parts close to and in front of 
the jaw, until it came out at the lower point of the space on the left side. 
The bistoury was then withdrawn, and a slender saw introduced in the same 
place, and the upper three-fourths of the jaw, containing the six front teeth, 
was sawed off on a horizontal line, ending at the bottom of the spaces before 
named, the detached portion being still connected, on the outer and inner 
sides, to the jaw below, by the soft parts. 

" After having with the bone nippers removed from the detached portion 
the corners which were created by the horizontal and perpendicular cuts of 
the saw, it was set back, so that the edges from which the V-shaped sections 
were removed came together. 

" Thus it will be perceived that this portion of jaw and teeth, which before 
projected and inclined outward, now stood back and inclined inward, and in 
its proper and original place. 

II In this position the jaw was secured by passing ligatures around the cus- 
pidati in the detached portion and the now adjoining bicuspids in the sound 
portion ; then, taking an impression of the jaw in very soft wax, a cast was 
procured, and a silver plate struck up and fitted over the teeth and gum, in 
such a manner as to maintain the parts in that same relation, beyond the 
possibility of movement. 

" The patient declared that the operation gave her little or no pain. There 
was a little swelling about the chin during the first three days after the opera- 
tion, but not the slightest uneasiness. In this way the case progressed; the 
gum healed in a few days, the jaws united strongly, and in the time bones 
usually unite, and the wearing of the plate was discontinued within six 
weeks after the operation was performed. 

" The deformity of the jaw being now removed, the next thing to be done 
was to relieve the confined condition of the head, and the distortion of the 
face and neck resulting therefrom. This I determined to accomplish, if 
possible, after the manner of Prof. Mutter in similar cases, and I accordingly 
performed the operation on the 31st day of July, assisted by Dr. Wissell. 

II I began by dividing the skin immediately in front of the neck, about 



11 



996 ORAL DISEASES AND SURGERY. 

half an inch above the sternum, and then carried the incision back about 
three inches on each side. I then commenced a careful division of the 
strictures, which were so thickened in front as to extend to the trachea, and 
on the sides as not only to involve the platysma myoides, but a portion of 
the sterno-cleido-mastoid muscle also. After dividing everything that inter- 
fered with the raising of the head and the closing of the mouth, as far as the 
incision was now made, it became evident that, to give free motion to the 
head, the incision on the neck must be extended back through the remaining 
cicatrix, which was at least two inches wide on one side, and about an inch 
and a half on the other. 

"This was accordingly done, the whole presenting a wound upwards of 
nine inches in length and nearly five in width. A thin piece of leather was 
now cut in shape of the wound, but somewhat larger, and placing it upon the 
shoulder and arm, immediately over the deltoid muscle, a flap nearly ten 
inches in length and five in breadth, having an attachment or neck two inches 
wide, was marked out, and then dissected up as thick as the parts below 
would permit. This flap was now brought around and secured in the wound 
on the neck by the twisted suture, the sutures being placed about an inch and 
a half apart. Between each of these sutures, one, two, and sometimes three 
small stitches were inserted, depending entirely upon the number necessary 
to bring the edges neatly together. These stitches were of fine thread, had 
a very superficial hold, produced little or no irritation, and served to keep 
the parts in better apposition than any other means I could have devised. 
The wound of the shoulder was next drawn together about one-half of its 
entire extent ; the remainder was covered with lint. One long, narrow strip 
of adhesive plaster applied around the neck to support the flap, and over this 
a cravat tied in the usual way, constituted all the dressing deemed advisable 
at this time. 

" The patient bore this tedious and very painful operation with great forti- 
tude, and uttered scarcely a murmur. She was somewhat exhausted, but not 
from the loss of blood. There was no vessel divided of sufficient importance 
to require a ligature. 

" August 1st. During the fore part of last night the patient was somewhat 
distressed, was very unmanageable, would talk incessantly, and occasionally 
sat up in bed. An anodyne was administered at twelve o'clock, after which 
she rested much better and slept some. Complains of sickness of the stomach 
this morning ; has vomited three or four times ; flap very pale ; pulse rather 
weak. Directed to refrain from all kinds of drinks. 

"2d. Complains only of pain in the shoulder; was much distressed the 
latter part of last night, on account of a retention of urine. The catheter 
was employed, and about three pints of urine drawn off, after which she 
rested well. Pulse somewhat excited ; flap better color. 

" 3d. The patient rested well last night ; the use of the catheter still neces- 
sary. All efforts to keep the patient from talking and moving unavailing ; 
color of the flap rather pale, save at the extreme point and about two inches 
along the lower edge, which is assuming rather a dark-blue color. Pulse 
about the same as yesterday ; removed a pin from near the point of the flap, 



OPERATIONS UPON THE LIPS AND CHEEK. 997 

and enveloped the neck in cotton batting. Patient complains of hunger; 
chicken broth ordered. 

" 4th. Patient rested well ; the use of the catheter yet necessary ; complains 
of slight headache ; the color of the flap nearly natural, and even the point 
is assuming a healthy hue, and appears to be uniting ; pulse almost natural. 

" 5th. Urinates without difficulty ; bowels moved by injections ; patient 
entirely free from pain ; pulse natural. 

"6th. Dressing removed; the flap is uniting by the first intention along 
both sides, throughout its entire extent ; the greater part of the pins and 
stitches removed. 

"7th. The remainder of the pins and stitches removed; patient perfectly 
comfortable and cheerful. 

" 10th. Sat up all day by the window. 

" 16th. "Walked out to take an airing. 

" During the whole progress of the cure there was not the slightest swelling 
or undue inflammation in the flap or about the neck. The patient was slightly 
hysterical for the first few days, but never complained of anything but pain 
in the shoulder, a slight headache of a few hours' duration, and the uneasiness 
occasioned by the retention of urine. The wound on the shoulder granulated 
rapidly and skinned over in about six weeks after the operation. It was 
curious to observe that upon touching the flap after it had healed in the neck 
the patient would always refer the sensation to the shoulder or arm from 
which the flap was taken. 

" The confinement of the head and the distortion of the face occasioned by 
the strictures being now removed, the next step was to relieve, as far as pos- 
sible, the very great deformity of the under lip. 

"The under lip, from being dragged down and greatly stretched by the 
former projection of the under jaw, was rendered greatly too large, so that it 
pouted out an inch or more farther than the upper lip. This, together with 
a turning out of the mucous membrane on the left side, which extended 
nearly down to the lower edge of the chin, making the lip too short on that 
side, was the nature of the deformity yet to be relieved. 

" To remove this unseemly appearance of the lip, the inverted portion was 
cut out in a V-shape, extending down to the flap in the neck, and sufficiently 
large to reduce the lip to its proper size. The edges were then brought 
together, and secured after the manner of a single hare-lip. The wound 
healed in the most beautiful manner, and the appearance of the lip was 
greatly improved ; but there yet remained a deep depression or notch in the 
edge, sufficiently large to keep exposed the tops of two or three teeth, besides 
preventing the coming together of the lips on that side. 

'•' I now determined to raise, if possible, this depressed portion of the lip, 
and for this purpose I passed a bistoury through the lip, about two lines from 
the free edge, first on one side of the depression and then on the other, and 
then carried the incisions downward to meet at a point on the lower edge of 
the chin. 

" The depressed portion of lip now lying between the two incisions was 
next dissected loose from the jaw, and then raised to a level with the re- 



998 ORAL DISEASES AND SURGERY. 

reminder of the lip, and there retained by pins, after the manner of dressing 
a double hare-lip, the line of union forming a letter V. 

" This operation was as successful as the others, and, the original deformity 
being now removed, the young lady, though still bearing evidences of the 
burn, has the free use of her head, eyelids, jaws, and lips, and may mingle 
in society without particular note or remark." 



Plate XIII 









CHAPTER XLYIIL 

RHINOPLASTY AND RHINO-CHEILOPLASTIC OPERATIONS. 

Defects of the nose, requiring relief through plastic operations, 
vary markedly in character : thus, the parts may be completely lost, 
or only one ala may be absent ; a break in the continuity of the 
side may exist, as shown in Fig. 330 ; or with the loss of one side 
may be conjoined a misshaped and sunken condition of the opposite, 
as seen in Fig. 326 ; nose and lip may both be wanting, as exhibited 
in Fig. 319; or, as is often seen, Y-shaped breaks may exist in the 
continuity of the free surface of one or the other of the alas. 

Four general features associate with the operations of rhino- 
plasty, namely : the Italian, the German, the Indian, and the 
English method. 

The Italian method is that known as the operation of Tagliacozzi. 
This is practiced by marking upon the inner and middle portion of 
the integuments of the arm two longitudinal lines four inches at 
least in length by three and a half in breadth ; the flap thus out- 
lined is now raised, and, while allowed to remain attached at either 
end, is separated its length from the underlying parts by well-oiled 
linen or sheet-lead passed beneath it. Allowed thus to remain until 
it becomes thickened and indurated, a period of some two weeks, 
the one end is detached, and the oblong flap, being pared into shape, 
is now stitched to the face, which has been prepared for its reception. 

The German method, being a modification of the preceding made by 
Prof. Yon Graefe, of Berlin, consists in the performance of the whole 
operation at a single sitting. This method, while advantageous as 
regards the comfort of the patient, yet fails to secure that thick- 
ness of substance in the flap which was the object with Tagliacozzi 
in subjecting it to such long-continued irritation ; also the shrinkage 
has to occur in the part, as a nose, rather than as a flap. 

The Indian method, the one most generally practiced, consists in 
taking the flap for the bridge and ala? from the forehead, and the 
columna from the lip. 

The English method, devised and first practiced by Prof. Syme, 
of Edinburgh, consists in taking flaps from the cheek, as is shown 

(999) 



1000 



ORAL DISEASES AND SURGERY. 



Fig. 324. 



for one ala, in Fig. 326. In this operation the coluinna is also to 
be obtained from the lip. 

Fig 5, Plate XIII., exhibits the flap, as made after the manner of 
Tagliacozzi ; also the manner of attachment to the face, together with 
the means practiced by that surgeon to fix the forearm over the head. 
Fig. 4 shows the Indian operation ; the general Y-shape of the 
flap, conjoined with the strip for the coluinna, is recognized in the 
ulcer on the forehead ; the flap, rotated on its pedicle, is seen to be 
raised in its new position into the shape of the nose by bougies 
introduced into the nostril-spaces. 

Studies. — Fig. 324 exhibits a case in which the alag and cartilagi- 
nous septum of the nose have been lost. In this case the defect is pro- 
posed to be remedied by material 
to be taken from the forehead, after 
the Indian method. First, the size 
and shape of the new wings are 
mapped out with ink, as shown. 
To so map out the organ it becomes 
necessary, first, to have a complete 
idea of what is needed; this is 
obtained by using a thin sheet of 
gutta-percha, which, on being 
warmed, may be moulded as de- 
sired. Obtaining thus the size, 
the material is spread out upon 
the forehead, as shown in the cut. 
It now remains to freshen the cir- 
cumference of the parts to be re- 
stored, and, dissecting the flap from the forehead, plenty being allowed 
for shrinkage, twist it upon the pedicle, which of course is allowed to 
remain, and by means of ligatures fix the flap in the new position.* 
The separation of the pedicle is only to be practiced after full re- 
lationship of circulation is established in the newly-related parts, — 
a period varying from ten days to as many weeks. 

The convex position of the new nose and the maintenance of the 
orifice are to be secured by tubes of silver, worn for several months. 
Fig. 325 shows a frequent result of such a rhinoplastic operation. 




* A manner of relating the parts, devised by Prof. Pancoast, is known as 
the tongue -and-groove suture: this consists in associating two surfaces by 
means of convex and concave faces. 



RHINO- AND RHINO-CHEILOPLASTIC OPERATIONS. 1001 



Fig. 326, being a case from the practice of Prof. D. Hayes Agnew, 
in which the author had the pleasure to assist, exhibits the loss of fully 
one-half the nose. In this instance it is perceived that, besides the 
loss of the ala, the remaining nostril, as the result of a cicatricial 
depression at the bridge, has been made to look unduly outward, 

Pro. 325. 



Fig. 326. 





Fig. 327. 



the organ being converted into a very decided pug. Two indica- 
tions are here seen to exist: first, the body of the nose is to be let 
down ; secondly, a new ala is to be made. Turning now to the lines 
of incisions, it is perceived how these indications were attempted to 
be met. First, across the bridge is seen 
the first cut made ; this incision, with a little 
dissecting, allowed the part to drop as re- 
quired; secondly, commencing upon the 
nasal prominence, as seen in the diagram, 
an incision was brought down, and, after 
extending a very short distance, was made 
to assume a triangular form, thus affording 
a pyramidal slip to occupy the triangular 
space necessarily resulting from the drop- 
ping of the nose; thirdly, continuing the 
line of incision, the cut was carried into 
the substance of the cheek, as shown in the 

drawing, the form of flap created being in accordance with the wants 
of the part to be restored ; fourthly, the edge of the nose was fresh- 
ened, and the triangular flap seen below was dissected to its base. 




1002 



ORAL DISEASES AND SURGERY. 



All being thus ready, the alae flap was brought into place and 
attached, while the inferior flap was forced outward to help fill up 
the space left vacant by the removal by the triangular apex of the 
alae flap. 

Fig. 327 exhibits an operation similar to that shown in Fig. 324, 
the new nose being here seen stitched in place, and the wound on 
the forehead approximated. 

Fig. 328 exhibits a facial loss of substance, together with the pro- 
posed mode of correction. 

Fig. 329 exhibits the flap, as made in Fig. 328, in place, with the 
wound of the forehead approximated, the various pins and stitches 
required being shown. 



Fig. 328. 



Fig. 329. 





Plate XIV. is one of the most valuable presented by Professor 
Smith in his System of Surgery, representing a combined operation 
in rhino-cheiloplasty,with the original appearance of the patient, the 
steps of an operation devised and executed by Professor Pancoast, 
and the result obtained as exhibited by an accurate likeness of the 
patient taken sixteen months after the operation. 

History of the Case. — The history of this case will serve as a 
type and study of similar cases. "A man aged fifty-three had lost 
all the soft parts of the nose and whole of the upper lip, from the 
commissures of the mouth to the canine fossa of each side, as well 
as the septum narium and the turbinated bones, the cavities of the 
antra Highmoriana and of the sphenoidal sinuses being exposed. 



Plate XIV 







SH^MS 














PLATE XIV. 

RHINOPLASTY AND CHEILOPLASTIC OPERATIONS. 

Fig. 1. — Appearance of John Glover prior to the operations of Cheiloplasty 
and Rhinoplasty. — After Pancoast. 

Fig. 2. — View of his face with the chin depressed. The mouth, being con- 
trad id into a rigid orifice, was enlarged laterally by the stomato- 
plastic operation of Diefienbach for atresia oris, after which two 
flaps were made, as marked in the lines upon the cheeks, so as to 
form the upper lip. — After Pancoast. 

Fig. 3. — Appearance of his face after this operation, showing the position of 
the sutures and the improvement in the mouth. — After Pancoast. 

Fig. 4. — Shows the steps of the Ehinoplastic operation performed upon him 
subsequently. The edges of the nasal cavity beiag freshened by 
a grooved incision, the outline of the new nose was marked on 
the forehead before cutting the flap. The dots indicate the posi- 
tion of the sutures. — After Pancoast. 

Fig. 5. — The wound in the forehead being closed by the hare-lip sutures, the 
flap was reverted, and attached in the groove on the edge of the 
nasal cavity by three stitches of the interrupted suture, which 
were tied over little rolls of adhesive plaster, after Graefe's 
method. The edge of the septum is also attached to the upper 
lip. The twist in the pedicle is seen in the root of the nose. — 
After Pancoast. 

Fig. 6. — An accurate likeness of John Glover, sixteen months after the 
operation. ^-After Pancoast. 



(1003) 



1004 ORAL DISEASES AND SURGERY. 

His appearance with his mouth closed is shown in Fig. 1. The 
mouth, when opened, presented a rigid circular orifice three-fourths 
of an inch in diameter. 

" Operation of Pancoast. — The mouth being widened after 
Dieffenbach's method (see description on previous page), the free 
surface of the gum was freshened, and an incision was then made 
obliquely upward and outward for a quarter of an inch from the 
point where the gum was covered by integuments, and from the end 
of this another cut was made for about the same distance, nearly 
parallel with the incisions for widening the mouth, but inclined a 
little downward. The cheeks being now loosened from the gum and 
malar bone by incisions on the side of the mouth, the flap of skin 
and subcutaneous fatty matter was raised from the surface of the 
muscle by beginning the dissection at the angle next the nose, Plate 
XIY., Fig. 2. 

" The arterial branches, which were divided, having been twisted, 
the flaps were drawn downward and forward over the raw surface of 
the gum, and fastened together with the hare-lip suture, Plate XIY., 
Fig. 3, the inner edge of the rotated flaps being thus united in the 
middle line of the lip. The face being then dressed with lint wet 
with lead-water and laudanum, the patient recovered in about two 
months. The nose was subsequently formed as follows: 

" The hair being shaved from the temple and forehead, the nasal 
orifices closed with lint to prevent the entrance of blood, and the 
patient lying down with the head supported by a pillow, a flap was 
raised from the forehead, as shown in Plate XIY., Fig. 4, the skin 
being divided at a single sweep of the knife, the blade of which was 
inclined outward so as to cut a beveled edge. The apex of the flap, 
which was about five-eighths of an inch wide, rested between the 
eyebrows, and the tongue-like portion which was to form the columna 
nasi extended up into the scalp. The base of the flap was nearly 
three inches wide, in order to allow for its subsequent contraction. 
The flap, after being dissected up, was then turned down on the 
left side and wrapped in linen, while the wound in the forehead was 
closed by four interrupted sutures, after which the flap was applied 
to the freshened edges of the new lip and gums, the whole being 
held in position by the plastic suture before described, and tied over 
rolls of adhesive plaster, as in Graefe's method, Plate XIY., Fig. 5. 
Union having occurred, the pedicle of the flap was divided, five 
weeks subsequently, by passing a director under it, after which it 
was smoothly fitted down to the roots of the ossa nasi, in a cavity 



XV 






Fid. 2 







e 





i : 



\ 




w 



f^^&w 







-<~- 







\ 



K 



PLATE XV. 

RHINOPLASTIC OPERATIONS. 

Fig. 1.— Restoration of one-half of the Nose and part of the Cheek by a flap 
taken from the Forehead. — After Pancoast. 

Fig. 2. — Side view of the same with the flap in situ, showing the arrangement 
of the sutures upon the cheek.— After Pancoast. 

Fig. 3. — Likeness of a Patient operated on for the removal of a Deformity 
caused by the destruction of the Hard Palate, Septum Narium, 
and all the soft parts of the Nose, with the exception of the lip 
and columna, these being distorted and fastened to the lower end 
of the ossa nasi. — After Pancoast. 

Fig. 4. — A view of the gap left in the Nose of Fig. 3, after the dissection of 
the cicatrix and depression of the tip of the nose. The outlines 
of the flaps cut from the cheeks to fill up the gap are also shown. 
— After Pancoast. 

Fig. 5. — A side view of the same, showing the application of the Sutures and 
the closure of the wounds left in the formation of the flaps.— 
After Pancoast. 

Fig. 6. — A front view of the same, showing the arrangement of the Twisted 
Sutures to both the nose and the wounds left in the cheeks.-— 
After Pancoast. 



(1005) 



1006 



ORAL DISEASES AND SURGERY. 



which was made for its reception by excising a portion of the sub- 
jacent integuments. By the twelfth day union was perfect, and the 
patient left the hospital so much improved that, sixteen months 
subsequently, his likeness was taken, as represented on Plate XIY., 
Fig. 6."— Smith. 

Fig. 330 exhibits a case which was of much interest to the author, 
inasmuch as the defect deformed the person of a fine-looking lady, 
and had twice been attempted to be cured by a plastic section 
from the cheek ; the flap in both instances had sloughed. Examin- 
ing the diagram, an irregular Y-shaped break is seen to exist in the 
right ala; this had been produced by the improper application of 
caustics for the cure of a supposed cancer. The character of opera- 
tion seen in the diagram yielded a most satisfactory result: this 
consisting in the employment of a double V-incision, conjoined with 
a second loosening of the ala at its external inferior angle from the 
cheeks ; these cuts made, the ala was slipped toward the mesial 
line and fixed in its new position by a pin. Passing now to the com- 
paratively lax nostril, a delicate hare-lip pin was passed through 
the apices of the two lesser triangles, and by means of the figure-of- 
8 ligature these apices were brought into contact, 
thus necessarily securing a proper curvature to the 
free border of the nostril. 

Referring to Plate XIII., Fig. 1, is seen the front 
view of a patient operated on by Dr. Watson, in the 
New York City Hospital, for the relief of a large 
ulcer, accompanied with syphilitic caries of the 
frontal bone ; the ulcer " is represented with thick- 
ened and inverted edges, and as retaining a portion 
of the necrosed bone. A fistulous orifice is also de- 
scribed as existing at the upper borders of each orbit, 
with another in the left temple, through which pus 
escaped freely. The upper eyebrows and upper 
eyelids are shown as slightly elevated and deformed 
by the adventitious adhesions existing around these 
fistulse." 

Fig. 3 represents the lines of incision practiced for the securing 
of flap-tissue to cover this ulcer, together with the approximation 
secured, and the appearance of sutures in place. 
Fig. 2 exhibits the relief secured by the operation. 
Another manner of treating facial ulcer, or indeed any ulcer, con- 
sists in the transplantation of particles of skin, as referred to on a pre- 



Fig. 330. 




RHINO- AND RHIN0-CHEIL0PLAST1C OPERATIONS. 1007 

vious page. These islands serve as points of cicatrization, and not 
unfrequently succeed most happily in covering an ulcer, and limit- 
ing to marked extent the boundaries of a cicatrix.* 

An accident occasionally met with by a class of persons who in- 
dulge in street-brawls, consists in the loss of the tip of the nose by 
the teeth of an antagonist. 

Fig. 331 affords an idea of the appearance of the part after such 
an accident. 

To treat such a case implies, first, consideration of the state of 
the wound. The incisor teeth of people differ very markedly, being 
in some of such knife-like edge that a wound made 
by them would really represent the ordinary incised -^ IGL 331# 

wound, and might be expected to heal with little or 
no slough ; teeth there are on the other hand 
known ordinarily as double, where the surface is 
found so broad and jagged that sloughing to a greater 
or less extent would necessarily associate with any 
wound made by them. This matter, however, is to 
be epitomized by remarking that such a wound is 
ready for operation when the surface is that of the 
ulcer described on other pages as healthy. 

In the case of a portion of nose bitten off, it is good 
practice, if the piece is quickly found and is not too much injured 3 



* The study of the subject of transplantation of tissue has recently received 
fresh impetus from the experiments which have been made in the direction 
of attempts to compel independent islands of skin to unite with and live upon 
an ulcerated surface without the support of a pedicle. The nutrition of such 
a piece of transplanted skin, and, in fact, the immediate union of any trans- 
planted flap, necessitates the rapid passage of vessels across the intervening 
space and the production of but little intermediate tissue. The formation of 
new blood-vessels in tissue is a subject so wonderful that it is well worthy of 
careful study. At some point on an existing vessel the wall dilates ; a pouch 
is formed ; it deepens, and a blind canal results. At the same time, at a point 
not far distant from the first, a similar action is going on, — one diverticulum 
projects backward, the other forward, each taking its course in the direction 
of the new tissue to be nourished or formed ; they extend, meet ; the inter- 
vening walls which closed their ends are removed, and a continuous arch is 
formed, through which the blood freely courses. Thus at every point these 
little offshoots or arms, microscopic in size, unite with similar ones from the 
same or adjoining vessels, until multitudes of little arches and natural anas- 
tomoses are formed, and nutrition is accomplished, every step being taken 
with precision, regularity, and dispatch. Thus marvelous are the actions 




1008 ORAL DISEASES AND SURGERY. 

to stitch and bind it in position. Nothing can be lost by so doing, 
and an easy repair may possibly be secured. Should, however, such 
result not ensue, the part is to be replaced by modifications of some 
of the various operations suggested. Or, most conveniently, it is to 
be done from a flap secured from the lips, as shown in the diagram ; 
this flap, shaped to fit the part lost, is twisted on its pedicle, and 
attached after the usual manner. The gap left in the lip is simply 
an expression of hare-lip, and is to be so treated. (See Operations 
for Hare-lip.) 

From the studies and illustrations offered, it is to be taken for 
granted that the ingenuity of the practitioner, directed by the hints 
afforded, will enable him to meet such varying indications as may 
from time to time be met with. The subject is a very interesting 
one, and will well repay the attention given to it. 



constantly taking place in our bodies to subserve the process of repair; and 
although man's capacity for the reproduction of lost tissue is infinitely less 
than that of lower beings, yet all of us must frequently be astonished at the ex- 
tent of reparative power exhibited by nature. As we descend the scale to crea- 
tures incapable of self-defense or self-preservation, the provision for the sus- 
tenance of existence becomes more marked, until, in protozoa, self-mutilation 
is but a common occurrence in case of danger, repair being so active that a 
short time sufiices to replace any member which may thus have been cut off. 
Man, endowed with powers of reasoning and defense, requires such provisions 
to a correspondingly less degree, and in him we find that repair exists in its 
least expression. Still, with our advancing knowledge, we may hope to assist 
nature even in this process, as exampled, for instance, in the reproduction of 
bone from preserved periosteum. — Clinical Report by Dr. De Forrest 
"VYillard. 



CHAPTER XLIX. 

PALATINE DEFECTS AND THEIR TREATMENT. 

In the treatment of any palatine defect, the first consideration 
necessarily is to be of its cause and condition. Thus, it will be 
found that such defects or deficiencies may, by influencing circum- 
stances, require treatment so modified or changed as to seem, in 
cases apparently similar, quite at variance with each other. 

For example, take two perforations exposing the nares; one con- 
genital, the other the result of disease. In the first of these cases 
any operation or appliance which would seem to promise relief 
might be adopted ; in the second we might justly pause at any inter- 
ference. No one in his senses would attempt the operation of 
staphyloraphy on a patient laboring under acute syphilis, or where 
a mercurial course had so broken down the crasis of the blood as to 
make a union by the first intention impossible, or even doubtful. 
No more would one be justified in attempting this or any other of 
the operations of expediency, with the constitutional conditions 
adverse to success, than he would be justified in avoiding the 
responsibility where such influencing associations were favorable. 

Cleft Palate. — The condition known as^cleft palate, to which 
we at once pass, may, from its exceeding frequency, be the first to 
claim attention. A cleft may be partial or complete ; that is, there 
may be a simple lengthwise division in that portion of the mouth 
known as the soft palate, or the cleft may be so extensive as to ex- 
tend from the uvula to the lip, a fissure separating both hard and 
soft parts. The first of these two conditions is found perhaps most 
frequently as the result of disease ; the latter is nearly always con- 
genital. Indeed, I do not recall a single case where I have met 
complete fissure as the result of disease. I have treated fissures 
produced by syphilis where there was a break both in the bone 
and in the soft palate, but never that I remember where a coexistent 
break existed in the continuity of the lip. 

Fissure of the hard palate the result of disease, differs, however, 
from the congenital form in a particular which I think would scarcely 

63 (1009) 



1010 ORAL DISEASES AND SURGERY. 

allow of the surgeon's being deceived. A fissure the result of dis- 
ease exhibits an irregular break in the continuity of one or both 
palatine processes ; a fissure having congenital origin exhibits, so 
far as my experience goes, the deficiency harmonious to the line of 
contiguity or in the palatine raphe, — this at least as the rule. 

Let us first consider the condition and treatment of the congeni- 
tal cleft. A child is born, toward whose mouth attention is first 
directed either by the nasal character of its cry, or, a little later, by 
its inability to take the breast properly; or the condition is marked, 
perhaps, by the break continuing through the lip, giving the de- 
formity which we have studied as hare-lip. 

When a child is thus unfortunate, and the attention of the sur- 
geon is called to the case, a single question presents itself, namely, 
how the deformity is to be corrected : if it be suffered to exist, every 
day will increase the difficulty of the cure, that is, so far as the most 
formidable part of the operation is involved, while if its correction be 
at once attempted, the prospect of complete success is very great. 

Fissure of the hard palate has generally been deemed irremediable, 
so far as operative means are concerned, and the surgeon has been 
taught to consider his whole duty done in describing to the parents 
the mechanical method which in after-life was to conceal and correct 
the trouble of his patient. Now, in this chapter I shall present a 
remedial surgery which is as practicable and feasible as any other 
of the operations of expediency, and perhaps I am justified in going 
so much further as to say that the modes of procedure will be found 
much more promising than the majority of such operations. Through 
the proper application of mechanical allied with the more strictly 
surgical means, I have not unfrequently succeeded in effecting 
changes in the young maxillary bones, a simple description of which 
might cause my veracity to be doubted ; and yet this ability to effect 
such changes must become very plain to us, if for a single moment 
we pause to consider the difference between the composition of the 
young and that of the old bone. Young bone, or bone at birth, as 
is well known, is almost if not quite half made up of animal material ; 
while in the osseous structure of the adult there is excess in the 
limy or unyielding material, from seventy-five to perhaps quite 
eighty-five per cent. 

To illustrate more familiarly this yielding constituent of bone, 
let me refer to the old experiment of the maceration of bone in dilute 
muriatic acid. We know that if we subject a bone to the action of 
this acid for one or two weeks, we may tie a rib like a whip-cord. 



PALATINE DEFECTS AND THEIR TREATMENT. 1011 

Now, we do this simply by reducing an old bone to somewhat the 
condition of a young one. I have removed a rib from a living young 
cat, and manipulated it in this same whip-cord manner. I have per- 
ceptibly bent the femur of a young child ; but no one, I imagine, 
ever performed such a manipulation on the healthy femur of the 
adult. You may take an inferior maxillary bone, even in a child 
of fifteen years, where the projection of the chin is so great as to pro- 
duce deformity, and with a properly-constructed vertico-mental elas- 
tic sling you may, in a period varying from three weeks to as many 
years, so change the angle of the bone as to do away entirely with 
the deformity. You may take the projecting myrtiform border, and 
through the instrumentality of the occipito-alveolar sling in quite 
a short period compel it to a natural articulation. On this known 
yielding character of the } r oung bone, therefore, operations for the 
correction of congenital fissures of the hard palate may be founded. 

A congenital fissure of the hard palate may be corrected instantly, 
or the cure may be effected slowly. The first of these procedures is 
applicable to such cases as present but a limited separation of the 
bones; the latter, when the fissure has considerable width. 

The operative procedure for the immediate cure is as follows : an 
instrument, a modification of the Hoey clamp, ordinary arterial 
compressor, or a Hainsby compress, is to be made by so arranging 
the pads that they shall apply to the sides of the jaws and allow of 
the force being so directed that the pads can be approximated with- 
out undue facial pressure. The clamp of Hoey, it will be seen, 
needs alteration only so far as the pads are concerned, and is quite 
easy of adjustment to this purpose. 

The instrument ready (the patient being in proper condition), the 
operator commences by paring the soft parts and bone on both sides 
of the fissure, beginning on the approximal faces of the palate-bones, 
and cutting forward to the alveolar face of the chasm. This part 
of the operation completed, the little patient may be allowed to 
rest until the bleeding ceases. The next step is to re-etherize and 
apply the compressor, the curved pads embracing the buccal faces 
of the alveolar arch; by now gradually turning the screw of the 
instrument, the yielding bones are brought together. The next and 
last step in the operation is to retain the parts in position by the 
use of compresses placed upon and below the malar bones, and 
secured by adhesive strips applied as in the occipito-labial cravat 
of Mayo. 

It may be urged against these manipulations that they are formi- 



1012 ORAL DISEASES AND SURGERY. 

dable and too heroic ; that fractures may result, etc. On these points 
the surgeon must decide for himself. I can only answer that, if 
carefully performed, it is not a dangerous operation; fracture of the 
bone, even if it should occur, would be of little consequence, as the 
parts have to be kept, as it were, in splints, and consequently the 
treatment of the one would be the treatment of the other. The most 
marked risk is from inflammation that may be provoked ; but a sur- 
geon not unfrequently has to run far greater risk for even a less 
result. 

Another mode of securing the same end, which is entirely divested 
of formidable risk, is as follows : take a circle of india-rubber tubing, 
the circumference of which shall be about one-third or one-half that 
of the child's head ; next prepare two firm compresses, of a size 
adapted to the case under treatment ; place these pads or compresses 
one on either cheek, in such position as will give them their rest on 
the buccal faces of the alveolar arch. Having secured them in place 
by one or more delicate strips of adhesive plaster, take up the ring 
of rubber and pass it around the cervico-labial diameter of the head. 
Passing over the compresses, it will thus exert, as is seen, a gradual 
pressure, serving to push the bone toward a common centre, this 
centre being the mesial line of the palatine arch. This process is a 
gradual one ; but, if the patient is young, I think it will be found to 
succeed ; the only real objection to the manipulation is the constant 
care necessary to prevent excoriation of the tender skin. 

When, by this procedure, the bony parietes have been brought 
into contact, the operation, so far as the hard palate is concerned, is 
completed by simply paring the folds of the mucous membrane. It 
may or may not be necessary to coaptate them : if the bones have 
been brought very close together, the granulations will alone be 
sufficient to bridge the slight remaining chasm. 

In either of these operations it is seen that the break, both in the 
soft palate and the lip, is not remedied. It is well, I think, not to at- 
tempt the cure of the lip until the patient has entirely recovered from 
the foregoing operation. It may then be performed, and, if done 
according to the rules given, will secure to the patient a lip so 
perfect that, in adult life, little or perhaps no mark of an operation 
will exist. The operation for the cleft in the soft palate must be 
left to a period later in life, for reasons presently to be alluded to. 

These suggestions for the cure of cleft in the hard palate were, I 
thought, original with myself, — though it is of slight consequence 
who invents an operation, so that it be good ; but in the periscopic 



PALATINE DEFECTS AND THEIR TREATMENT. 1013 

department of the Dental Cosmos I find the following extract, taken 
from the Australian Medical Record and Dublin Medical Press, 
which shows that the operation was conceived by another before it 
presented itself to my mind. The extract is a short one, and so 
apropos to the matter that I shall take the liberty to present it 
entire: 

" Pressure in the Treatment of Cleft Palate. — I am not aware," 
says the author, "that the subject of using pressure in treating fis- 
sure of the palate has been before suggested. I am inclined to think 
that it has not ; for when the plan first presented itself to my mind, 
in 1851, I carefully examined French, German, English, and Ameri- 
can works to see whether it had. I was first led to try it on the 
dead body of a child, which had died three weeks after birth. The 
fissure was longitudinal, and large enough to admit the extremity 
of the little finger; fissure of the lip also existed. By means of a 
pair of clamps, the sides of the fissure were brought readily in con- 
tact, without any fracture or displacement of the bones ; the only 
fault was that the gums of the upper jaw were within those of the 
lower; but nature would modify this as the living child grew up; 
the use of pressure on the lower jaw would remove a great deal of 
this deformity ; of course the amount of deformity would depend on 
the size of the fissure in the palate. I several times repeated the 
experiments on young dogs, removing a piece of the palate-bone by 
means of Hey's saw, and then applying the pressure. The animals 
did well. 

"The operation should be performed as early as possible after 
birth, when the bones are in their softest condition. The following 
is the plan which I would suggest: the edges of the fissure having 
been pared, the superior maxillary bones should be embraced by a 
horseshoe-shaped clamp, with a shelf on its lower border to receive 
the gums and prevent it slipping. It should be padded with india- 
rubber or some other material, to prevent the germs of the teeth being 
injured. The clamp should work on a joint, and possess arms. It 
may be said to resemble a large pair of pincers with horseshoe-shaped 
blades. A screw may be attached at the extremities of the handles, 
for the purpose of bringing the blades in contact, or the hands may 
be used : the former would be, I think, preferable, as the force could 
be applied gradually, and not be likely to be carried too far. It may 
also be employed in grown-up children, when the bones are so widely 
separated as to render it difficult to get soft parts enough to close 
the opening, but in a gradual manner and at intervals more or less 



1014 ORAL DISEASES AND SURGERY. 

prolonged, according to the amount of pain it excites. If it were 
used suddenly it might produce inflammation, and subsequently 
abscess, which would prove troublesome to treat. From the 
foregoing it will be, I hope, understood that the younger the 
child the safer the operation is likely to prove, and that even in 
grown-up children it may be adopted, with precaution, with decided 
benefit. 

"The pads and the ledge to rest the teeth upon should be made 
to slide in the sides of the clamp : the former, that the pressure 
may be directed on any part of the bones ; the latter, that the 
edges of the teeth may rest on it, without the pressure being 
directed either too high or too low, but at the point where the 
palate-bone joins the superior maxillary." 

We pass now to the consideration of the treatment of the fissure 
in the soft palate. This operation is known as staphyloraphy, a 
term derived from two Greek words, which signify suture of the 
uvula. As generally practiced, it is rather difficult of performance, 
and so frequently unsuccessful that surgeons seem disposed to avoid 
the responsibility of it. I propose here to suggest for consideration 
a new mode of performing the operation, which renders the manipu- 
lations as easy of accomplishment as by the old mode they are 
tedious and difficult. 

Preparation of the Patient. — For weeks before it is designed to 
perform this operation, preparations are made for it by subjecting 
the parts to such daily manipulations as shall educate to forbearance 
the natural sensibility of the fauces. In the absence of such prelimi- 
nary manipulation, the retchings and spasmodic twitchings are such 
as to render a proper performance of the operation, without the use 
of an anaesthetic, almost an impossibility. With such education, the 
parts will be found to assume, in a reasonable time, quite a stoical 
indifference to even severe irritants. This forbearance is secured 
by roughly fingering the part daily. I think it is not amiss to 
pass occasionally the point of the tenaculum through the parts to 
be operated upon. I never knew the trifling wound to give any 
trouble; and the double advantage is gained, if the part be put on 
stretch, of securing an estimate of the capability of the velum to 
be brought to the mesial line, — an important item in the operation, 
as will be easily appreciated. Some surgeons are in the habit of 
daily tickling the parts with a fine brush ; this, I should suppose, 
would answer a very good purpose. A very admirable idea, and a 



PALATINE DEFECTS AND THEIR TREATMENT. 1015 

most successful one, is to have made an obturator,* which shall 
extend back to the palate-border, or nearly to it. This is to be 
placed in the mouth, and, as soon as the irritability it produces is 
so far overcome as to permit of its permanent retention, the bands 
attached to it are to be clasped firmly about the necks of the teeth, 
and it is worn continuously for one or two months. When the parts 
have thus submitted to the presence of an obturator, they will be 
found quite ready for any operation. 

On the evening before the clay of operation, let a saline cathartic 
be given the patient, particularly if he be robust and strong. The 
meal immediately preceding the performance should, I think, always 
be a substantial one, for it is to be remembered that the patient is 
to have little to eat for some time. 

In operating on a depressed and anaemic patient, let his defi- 
ciency in vital forces be first considered, and, as far as possible, let 
it be corrected. If such attention is neglected, we will be almost 
sure to make a failure : the parts will not unite. Exercise in the 
open air, generous living, and the iron tonics may be prescribed. 
To sum up all in a single sentence, the preliminary treatment must 
meet the indications of each particular case. If, for example, you 
should operate on a scorbutic patient, or a patient disposed to 
purpura, without correcting such dyscrasia, you would be no more 
Sikely to gain union of the parts brought together than in an opera- 
tion on the cadaver. 

The surgical anatomy of the part must be fully understood. So 
much of success depends on a thorough knowledge of the muscular 
relation to the cleft that such acquaintance would give a success where 
otherwise a failure would be sure to result. This anatomy we may 
study before taking up the steps of the operation. 

To get a correct idea of the soft palate, we should commence the 
study of it by first carefully examining the parts on the living sub- 
ject. When we look into a living mouth, we see an arch stretching 
from every portion of the alveolar edge backward and inward, toward 
the fauces, terminating in a tongue or uvula, pendent in a horizontal 
direction from its centre. One-half of this arch is seen to be fixed, 
the other — the posterior half — is seen to be in almost constant 
motion. If now the finger is carried into the mouth, the fixed part 
is found to correspond with the boundaries of the palatine faces of 

* A description of this instrument and of its proper use will hereafter be 
given. 



1016 ORAL DISEASES AND SURGERY. 

the maxillary and palate bones ; that is, for a certain extent, you 
feel that the parts are solid, as if the finger passed over an arch of 
bone which might be covered alone by mucous membrane ; and this 
is in fact about the case. The finger traverses the anterior bony 
border of the mouth, or the hard palate. As now the finger is 
passed backward, it falls over a hard ridge upon parts that are soft 
and yielding ; this hard ridge is the posterior face of the palate- 
bone, and terminates the hard palate. The part upon which the 
finger has fallen is the veil or soft palate, the part that was observed 
to be movable. This is the part in which occurs the rent, or cleft, 
for the cure of which is demanded the operation we are about to 
consider. 

The mobility of this part, which pertains to its function, depends, 
as may be anticipated, on an associated muscular structure. To 
study properly this structure, which it is all-important to understand 
and appreciate practically, the student should take up the scalpel and 
pass to the cadaver ; it is, perhaps, only by dissecting that a really 
satisfactory idea of these muscles can be secured, — that is, as pertains 
to that kind of knowledge which gives confidence when we come to 
perform operations upon the part. 

The external coat or covering which we see on every mouth, 
living or dead, is the mucous membrane, — simply the continuation 
of that which covers the hard palate ; but while in the case of the 
hard palate we find all the underlying structure osseous, in the soft 
palate we discover this deep tissue to be made up exclusively of 
muscular tissue, — at least so far as a surgical anatomy is concerned, 
or as it serves our purpose here to study it. 

Commencing with the mesial line, we can dissect out the attach- 
ment of five muscles, each of which is of course duplicated on the 
opposite side, and each of which has such relation to this mesial 
line that, in case of cleft or split, it serves more or less to draw 
away the parts postero-laterally. 

These muscles, mentioned in the order of their signification to 
this lateral displacement, and consequently in their relation to the 
operation of staphyloraphy, are the tensor palati, palato-glossus, 
levator palati, palato-pharyngeus, motores uvulae. Of all these 
muscles the tensor palati plays the most important part, and is 
therefore entitled to the closest consideration. 

This muscle arises from the scaphoid fossa at the root of the 
internal pterygoid plate, from the anterior surface of the Eustachian 
tube, and from the spinous process of the sphenoid bone. If you 



PALATINE DEFECTS AND THEIR TREATMENT. 1017 

carry your finger (in your own mouth) back to the wisdom-tooth of 
the superior jaw, and let it drop over and back of this tooth, it will 
fall on the tuberosity of the maxillary bone; carry it now half an 
inch farther back, and it will come to a second prominence ; this is 
the hamular process of the pterygoid plate of the sphenoid bone. 
Now, the tensor palati muscle descends from the origin of which 
we have just informed ourselves, and, meeting this hamular process, 
it winds — as a tendon — around it, and then, by a fan-like expansion, 
spreads itself over the soft palate. Its action is evident : it expands 
the palate laterally. 

To perform successfully the operation for cleft palate, it is perhaps 
desirable, in every case, that the strain made by this muscle should 
be taken off. A moment's reflection will show us that the action of 
the muscle, in case of a cleft, would, when the parts were brought 
together, be much increased over its natural capability, not only 
because it would be put considerably on the stretch, but also because 
such stretch would, more than likely, excite it to a spasmodic con- 
traction. The muscle of course is then to be divided ; and we may 
as well here, as anywhere, consider the easiest point at which such 
preliminary operation can be done. 

It is remarked that the muscle is found winding — as a tendon — 
around the hamular process. It winds from the back, and out- 
wardly, inward, and forward, so that just in front of the process, 
between it and the tuberosity, is the place at which its section may 
be best performed ; there are here no important vessels to be 
wounded, if we except the posterior palatine artery and nerve, and 
these hug the base of the tuberosity so closely that it would, I think, 
have to be a very badly-managed knife that should interfere with 
either of them. The cut should be a little oblique. The inter- 
ference with function, as in most cases of myotomy or tenotomy, 
would be of course but temporary. The action of the muscle would 
be found recovered quite as soon as our cleft operation would be 
ready for it. 

The next most important muscle is the palato-glossus ; this is 
simply the anterior half-arch, the constrictor isthmii faucium. It 
arises, as will be seen, from the soft palate on either side of the 
uvula, and, passing outward, is inserted into the sides of the tongue, 
blending with the fibres of the stylo-glossus muscle. 

The palato-pharyngeus arises from the soft palate by an expanded 
fasciculus, and, passing outward, goes to be inserted into the poste- 
rior borders of the thyroid cartilage. These muscles constitute the 



1018 ORAL DISEASES AND SURGERY. 

posterior half-arches. Section of the palato-pharyngeus and the 
palato-glossus is to be made through the substance of the muscles, 
and is accomplished simply by nicking, somewhat deeply, the arches, 
— four cuts, one to each arch. These nicks are best made with 
scissors. 

The levator palati muscle arises from the petrous portion of the 
temporal bone, passes into the interior of the pharynx, and then 
descends obliquely downward and inward, spreading its fibres out 
over the posterior surfaces of the soft palate as far as the raphe. 

The action of the fifth and last muscle, the azygos uvulae, it is 
perhaps not absolutely necessary to consider, — its influence, for 
separation of the wound, being very trifling. 

Section of the levator palati is thought to be easiest of perform- 
ance after the manner suggested by Mr. Pollock. This gentleman 
first puts the flap on stretch, and then, with a double-edged knife, 
makes an incision through the soft palate just on the inner side of 
the hamular process. The handle is now alternately elevated and 
depressed, a sweeping cut being made along the posterior surface of 
the soft palate. 

The other anatomical elements of the soft palate are glandular 
structures, vessels, nerves, etc., all associated, more or less inti- 
mately, by connective tissues ; but these need not be particularly 
referred to, as one could not well dissect out the muscles without 
necessarily familiarizing himself with them. Thus, then, we under- 
stand the surgical anatomy proper of the parts, — the anatomy as it 
has relation to cleft palate. 

The operation of staphyloraphy was first practiced by a dentist 
of Paris, — La Monier. It has for its object the bringing together of 
the separated portions of a cleft soft palate and the retention of the 
parts in apposition until nature shall unite them. 

The operation consists of four different stages, with an object to 
be attained by each stage : 

1st. The paring of the edges of the cleft. 

2d. The introduction of ligatures. 

3d. The bringing together of the freshened edges, and fixing the 
ligatures. 

4th. The relief of any tension on the ligatures that may attend 
the approximation of the parts. 

These are the steps or stages, and to accomplish them various 
means and instruments have been devised, — some good, some bad, 
some indifferent. The reader curious in such matters will find an 



PALATINE DEFECTS AND THEIR TREATMENT. 1019 

admirable and most instructive chapter on the subject in the System 
of Surgery, published in 1851, by Professor H. H. Smith, of the 
University of Pennsylvania. In the chapter therein devoted to 
staphyloraphy is given a synopsis of the operations as practiced 
by surgeons whose names have been and are particularly asso- 
ciated with the subject. 

An epitome may be made of this chapter by noticing that the 
operation first suggested by La Monier, in 1764, was revived by 
Graefe, of Berlin, in 1817, but first methodized and published, with 
the rules for its performance, by Roux, of Paris, about 1819. In 
1820 a nearly similar operation was performed by Dr. John C. 
Warren, of Boston, he being at that time ignorant of the views or 
operations of other surgeons. In many respects the steps proposed 
by Drs. Warren and Roux correspond, though the means suggested 
by Dr. Warren are simplest, the operation of the latter being, how- 
ever, generally regarded as the basis of the various modifications 
that have since perfected the proceeding. 

The instruments prepared by Roux for performing the operation 
are alluded to as being sufficiently complicated. To execute the 
manipulations, he seated his patient before a strong light, with his 
head thrown back and supported against the chest of an assistant, 
the mouth being kept wide open by means of a cork placed be- 
neath the molar teeth. The surgeon then placed himself in front, 
and, with forceps held in the left hand, seized the right lip of the 
fissure. With his right hand armed with a needle-holder, he next 
introduced the point of the needle from before backward behind the 
uvula, in order to traverse the flap from behind forward, at three or 
four lines from the free edge of the fissure. The needle, being thrust 
in as far as its head, was then freed from the needle-holder, and 
seized at its point by forceps, which drew it and the ligature through 
into the mouth. After permitting a few minutes of rest to the 
patient, the same manoeuvre was practiced on the left side of the 
fissure with the other needle of the same ligature, the two ends of 
which were thus brought out into the mouth. In passing these 
ligatures, M. Roux commenced with the lowest, next passed to the 
highest, and ended with the middle. 

The next step in the operation of Roux was to freshen the edges 
of the fissure. This he accomplished by seizing the margins, as 
before, with his forceps, and paring from behind forward. 

To tie the ligatures, this surgeon commenced by knotting the 
middle one with the fingers, and, after making a simple knot, con- 



1020 ORAL DISEASES AND SURGERY. 

fiding it to an assistant, who held it with an instrument termed by 
the French a serre-noeud (knot-tier) ; he then passed on to the 
second ligature, and from that to the first, drawing them tighter 
than was necessary to approximate the edges of the wound, in order 
to prevent any separation. Eating, drinking, and speaking were 
interdicted the patient for from two to three days, the ligature 
being removed on the third or fourth day, excepting the lowest 
one, which was allowed to remain twenty-four hours longer than 
the other. 

Dr. John C. Warren performed the operation as follows. The 
patient being well supported and secured, a piece of wood, an inch 
wide, a little curved at the end, and with a handle to be held by an 
assistant, was placed on the molar teeth of one side to keep the 
mouth open. A sluirp-pointed curved bistoury was then thrust 
through the top of the palate, above the angles of the fissure, and 
carried down on one edge of the cleft to its extremity, and the same 
was done on the opposite side, so as to cut out a piece in the form 
of a letter Y, including about a line from each edge. Next a hook, 
or curved needle, fastened in a handle, with an eye on its extremity, 
and a movable point, armed with a triple thread of strong silk, was 
passed doubled into the mouth through the fissure behind the palate, 
and the latter pierced by it one-third the length of the fissure from 
the upper angle of the wound, so as to include about three lines of 
the edge of the soft palate. The eye, with the ligature, being seen, 
was seized with a common hook and drawn out. The eyed hook 
was then drawn back, turued behind the palate, and the other edge 
transfixed in a similar manner. A second and a third stitch were 
now passed in a similar manner, the third being as near as possible 
to the lower end of the fissure. Then, seizing the upper ligature 
with the finger, the knot was tied without using a serre-nceud, and 
placed on one side of the wound in order to prevent its pressing on 
the fissure, the other being tied in like manner, and the fissure closed. 

After the first operation of Dr. Warren, Dr. A. H. Stevens, of New 
York, in September, 1826 (see Norlh American Medical Journal, 
vol. iii. p. 233), operated successfully, by first inserting the ligatures 
and then paring the edges. 

In 1827, Dr. Mettauer, of Yirginia, operated for staphyloraphy, 
and in 1837 published an excellent essa}^. Dr. M. employed leaden 
ligatures. (See American Journal of the Medical Sciences, vol. xxi. 
p. 309.) 

Allusions are made in this chapter to other operators and opera- 



PALATINE DEFECTS AND THEJB TREATMENT. 1021 

tions ; but, as they are all only modifications of the methods of Roux 
and Warren, it is not necessary to refer to them. 

Several years back I had in my possession a monograph on the 
subject of staphyloraphy from the pen of the late Prof. Mutter. I 
regret that I cannot now lay my hands upon it. Dr. Mutter was 
much interested in the operation, and his pamphlet abounded in cases 
illustrating his success in this direction. 

To Mr. Fergusson, of England, however, more than to any other 
man, perhaps, are we indebted for a scientific appreciation of the 
requirements in stapb} T loraphy. The cutting and sewing parts of 
the operation are simple mechanical manipulations, which are of 
consequence only as they tax the ingenuity of the surgeon. The 
proper surgical understanding of the subject consists, as we are 
prepared to see, in a just acquaintance with the muscular relations 
of the parts. These relations we have already studied. To Mr. 
Fergusson belongs the credit of first making these demonstrations. 
It is very true that before his time incisions in the soft parts had 
been advised. Roux, Diefienbach, Mettauer, Liston, and Warren 
all practiced them where difficulty was met with in approximating 
the fissure ; but the incision practiced by them, as remarked by Mr. 
Fergusson, seems to have been without reference to the anatomy of 
the parts, and, as a consequence, rendered success somewhat a matter 
of accident. The operation of Mr. Fergusson, so far as the paring 
and bringing of the fissured parts together are concerned, is much 
the same as that practiced by Dr. Warren. He pares the cleft before 
inserting his sutures, and his knots are made about as Dr. Warren's. 

In looking over the history of staphyloraphy, the reader will be 
struck with the likeness in complaints, the three principal of which 
seem to be the difficulty in tying the ligatures, the great tendency of 
the ligatures to slough out after they are once nicely secured, and 
the concealment of the parts during operation, both because of defi- 
ciency in light and the accumulation of the viscid muco-saliva which 
in mouths thus affected is secreted in such abundance. 

Now, in the direction of operations in and about the oral cavity, 
I have had that experience and that practice which will, perhaps, 
justify me in asserting that there is an easier and more philosophical 
mode of performing the operation of staphyloraphy than has yet 
been practiced. To sit in front of a patient and operate in the mouth 
is most unhandy. The operator is in his own light; besides, it 
is certainly much more difficult to operate sitting than standing: 
motion is cramped, freedom is interfered with. To operate on the 



1022 ORAL DISEASES AND SURGERY. 

mouth of a patient, when the surgeon is seated in front, renders 
necessary an assistant, whose office it is to manage the head. This 
has a twofold objection. In the first place, the assistant cannot 
follow in all those little changes which are so necessary to success. 
He does not see quickly the shiftings and turnings which so assist 
in the manipulations. Again, one is more naturally ambidextral 
when the arras are supported than when they are unsupported. In 
operating sitting in front of a patient, the surgeon raust work at 
arm's length ; he has nothing to steady him, — no guard which shall 
enable him to shield himself against any sudden awkward move- 
ment on the part either of the assistant or the patient. 

To make a knot in a deep canal, such as the mouth or the vagina, 
is not easy. To fix a ligature by compressing something upon it is 
very simple. Silk acts as an irritant to human tissue, — silver or 
lead does not ; therefore, where it is desirable to retain a ligature 
for several days or weeks, without irritation, metal is best adapted. 

Instruments perfectly suited to an operation simplify it greatly. 

Predicating an operation on these self-evident truths, I commend 
the following as the best and easiest mode of manipulating, believing 
that where once practiced it will take precedence of all other modes. 

The instruments required are those belonging to the ordinary 
vesico-vaginal case, — -the long-handled knife, needles, and needle- 
carrier, shot-carrier and compressor, tenaculum, cutting forceps, 
silver or lead wire, the perforated flat shot of McLean, and mop- 
sticks. Better instruments than these for the operation of sta- 
phyloraphy will not, I think, soon be devised. The instruments 
arranged on a tray in the order in which they are to be used, the 
patient, having had the steps of the operation explained to him, — for 
much is expected from him, — is seated on a chair having a movable 
head-rest: it is well if this rest moves in a ball-and-socket joint; at 
any rate, it must be movable backward and forward. The ordinary 
dental chair answers the purpose admirably. When the head is 
placed on this rest, the mouth will be found to look directly upward. 
The surgeon now takes his position back of the patient, standing on 
a footstool of such height that his breast shall be brought on a level 
with the head of the patient. If the reader is disposed, he can thus 
seat a friend, and, taking a position back of him, by leaning over his 
head he will find that when the mouth is opened he not only has a 
most perfect view of a thoroughly lighted cavity, but by leaning 
against him, and passing his arms around the head so as to bring 
the hands to the mouth, he will perceive that, besides having his 



PALAT1XE DEFECTS AND THEIR TREATMENT. 1023 

own arms so steadied as to allow of the easiest manipulation, he 
has the movements of the patient completely under his control. 

Now, this relative position of the surgeon to his patient gives him 
not only the advantages enumerated, but he is out of the way of all 
expectorative efforts. If saliva and blood should accumulate about 
the parts at which he is working, he can and will, almost uncon- 
sciously, arid certainly without effort, so turn the head that, while 
he does not at all interfere with his own manipulations, he throws 
the fluid into some more convenient part of the mouth. This I 
know can be done so readily that each step of the operation may be 
accomplished without the annoyance and delay experienced in using 
the mop. Certainly, a patient so held cannot make any movement 
too quickly or too unexpectedly for the surgeon. True, he might be 
so obstreperous that the operation could not be accomplished ; but 
he could not make any change which the knife of the operator would 
not intuitively follow, and therefore any accidental harm could not 
be done. 

Patient and surgeon being thus in position, the tenaculum is taken 
up and carried through the very point of the cleft pendulum. See 
Fig. 2, Plate XVI. The part is then put on stretch, and a paring 
(as shown in the diagram) of about a line is taken from the whole of 
that side, cutting from behind forward. The manipulation is repeated 
on the opposite side. The first stage completed, very dilute compound 
tincture of capsicum, 3iij to ^xvj of water, or water medicated with 
cologne, is given the patient, with which to gargle and wash the 
mouth. These I find to cleanse the mouth admirably, besides acting 
as healthy stimulants. 

The bleeding arrested and the patient a little recovered, the sec- 
ond step of passing the ligature may be attempted. Take up one 
of the curved needles, and, threading it with the silver wire, fix it 
in the needle-carrier. Passing now the instrument into the mouth, 
thrust the needle through one side of the cleft, about three lines 
from the margin and about half an inch from the apex of the cleft 
or hard palate. After passing it to the point at which it is held by 
the carrier, it is to be caught by the forceps and brought through, 
the slide of the porte being loosened so as to permit of such with- 
drawal of the needle from its beaks. This accomplished, the needle 
is to be replaced in the porte and carried through the opposite side; 
relieving it from the grasp of the carrier as before, the two ends are 
brought from the mouth and their relation is secured by one or two 
twists. This completes the first ligature. A second is now passed 



PLATE XVI. 

A FRONT VIEW OF THE OPERATION OF STAPHYLORAPHY. 

Fig. 1. — The operation as practiced by Roux. 1. The needle-holder (porte- 
aiguille) in the act of carrying the last ligature through the right 
side of the fissure. 2. Dressing forceps holding this margin. 
3. The first ligature as placed, the ends being brought out 
through the angles of the mouth, and the loop being loose behind 
the palate. 4. The second ligature as introduced. 5. The third 
ligature. — After Bernard and Huette. 

Fig. 2. — The three ligatures, 3, 4, 5, as before shown, being accurately placed, 
the surgeon proceeds to freshen the edges of the fissure with a 
probe-pointed bistoury, taking care not to cut the loops of the 
ligatures. 1. Forceps holding the free end of the palate. 2. 
The bistoury paring off a strip. — After Bernard and Huette. 

Fig. 3. — Operation of Warren. 1. The knife freshening the edge of the fissure 
from above downward. 2. The forceps steadying the margin so 
as to favor its regular incision. — Modified from Pancoast. 

Fig. 4. — The introduction of the Suture by means of Physick's forceps and 
a curved needle. 1. Physick's forceps introducing the needle. 
2. Dressing forceps seizing its point at the moment when it is 
liberated from the instrument of Physick. 3, 4, 5. Position of 
the sutures. They should all be introduced at equal distances and 
as nearly parallel as possible. — After Pancoast. 

Fig. 5. — The operation of Staphyloplasty, as practiced by Dieffenbach. 1, 
2, 3. The sutures as tied, and closing the fissure. 4, 5. The two 
longitudinal incisions made on each side of the soft palate, so as 
to remove the strain from the line of union. — After Bernard and 
Huette. 



(1024) 



Plate XVI 



K 8 





/ K 



€>' 



rip.3 



Fi £ . 4 . 2 




Fig. 



PALATINE DEFECTS AND THEIR TREATMENT. 1025 

half ail inch farther on, also a third, or more, as may seem needed. 
The manipulations required are of course the same as for the first. 
This completes the second stage, and the patient is allowed to rest 
as before. If he needs to wash his mouth, the surgeon must look 
carefully after his ligatures. 

The third stage, or approximation of the edges, is next to be 
accomplished. Take up the shot-carrier, and, slipping through its 
fenestra the twisted ends of the first ligature introduced, push the 
carrier down the wires, and you will find, as it approaches the palate, 
the edges of the cleft approximate. This, I think, will always be 
found to be the case with the ligature nearest the hard palate : the 
parts come together very easily. You now slip off the carrier and 
take up one of tlie perforated shot ; put this on the wires, and with 
the carrier force it down to the palate. Holding it now in place, 
which is done simply by laying the wires against the carrier and 
shifting your finger over it, take up with the right hand the forceps, 
and compress the shot tightly upon the wires. The parts up to this 
ligature will now be found nicely approximated and fixed. This 
completed, repeat the operation on the second ligature. But this 
will be found, perhaps, impossible, without greatly overstraining the 
parts and risking the tearing out of the wire. 

If this is the case, you at once desist from the attempt, and make 
the section as described of the tensor palati muscles on either side. 
Now most likely the parts will come together comfortably : if so, 
fix them with the shot as before ; if, however, an approximation has 
not yet been secured, nick the anterior half-arch ; and if this does 
not suflice, cut the posterior and the levator palati : the ligature may 
then be fixed, as well as those still farther back. Each shot firmly 
compressed, the wires are to be cut off as closely as possible. Thus 
the third and fourth steps of the operation are completed, and 
nothing remains but to enjoin on the patient the most perfect rest. 
Herein lies half the secret of success : the patient should scarcely 
move for two or three days ; certainly he should not be permitted 
any food that would demand for its comminution the slightest effort 
of mastication. He should be directed to allow the liquids he may 
take to trickle down his throat, rather than to attempt to swallow 
them. These restrictions need not, however, be made quite so strict 
if in the operation myotomy of the half-arches has been performed. 
In the old mode of performing the operation, it was found neces- 
sary after the first day or two to remove the ligatures, because 

64 



1026 ORAL DISEASES AND SUBGERY. 

of their tendency to slough out : the use of silver wire obviates this 
necessity to a great extent, as the metal seems to provoke no inflam- 
mation. These ligatures may therefore, if they seem useful, be allowed 
to remain from one to three weeks. This non-irritating qualit^y of 
metal ligatures is so marked that I have seen them, when applied 
on varicose veins, as firmly fixed after four months as the first day 
they were put on. This is the feature which adapts such ligature- 
material so admirably for staphvloraphy. 

The wounds made in dividing the muscles may be left to nature. 
If the patient is in condition for the principal operations, he is in a 
condition which does away with any necessity for care in trifling 
flesh-wounds ; if, however, any trouble should arise in such a direc- 
tion, the practice would be that which would apply to similar wounds, 
however made. 

It is seen that the manipulations here suggested for the cure of 
cleft palate are precisely the same as those practiced in vesico-vaginal 
fistula, and that the instruments adapted to the one are exactly suited 
for the other. 

The position in operating is, I think, a new suggestion, and is 
founded on a somewhat extended experience in manipulating upon 
and about the mouth. To the author it seems the proper one for 
performing the operation easily and comfortably ; the advantages 
which it possesses over the old mode of sitting down in front of the 
patient are so easily studied upon the person of any one, that I trust 
the suggestion will receive the attention it will be found to merit,* 

From this consideration of cleft palate proper, we may pass to the 
study of other defects of the parts. 

Holes in the Palate. — Breaks in the continuity of the palate 
may be treated in two ways : either by an operation strictly sur- 
gical, as reference may be had to the use of the knife; or, by means 
which might be denominated surgico-mechanical. If the knife is to 
be exclusively used, we have simply to pare the edges of the break, 
and then get the parts in apposition as best we can. Herein consists, 
however, the difficulty of such operations ; and the tact and knowledge 
of the surgeon will prove his best guides. If the breaks are in the 
soft palate, any resistance that may be met with is to be overcome 



* These manipulations were first practiced and described in papers published 
by the author in the Medical and Surgical Reporter in 1861. 



PALATINE DEFECTS AND THEIR TREATMENT. 1027 

precisely as we would overcome it in staphyloraphy : let the sur- 
geon consider what muscle or muscles oppose him, and divide them 
as before suggested ; or, if myotomy seems scarcely necessary, he 
can in all probability accomplish his purpose by making lateral slits 
through the mucous membrane alone, or otherwise he may go a 
little deeper, making a kind of semi-myotomy. 

If the break be small, one ligature will perhaps be all that is 
necessary to secure the approximation of the pared edges ; this suture 
is to be made and fixed precisely as in the previous operation. If 
more than one suture seems indicated, of course more are to be 
employed. 

Defects in the hard palate are also amenable to surgical skill : 
they may be remedied by the use of the knife and stimulating local 
applications, or, if these fail, an artificial palate, properly constructed, 
will so admirably supply the deficiency that the patient is rendered 
almost as well off as his fellows. 

Using the knife alone, most successful results are frequently at- 
tained by first paring the edges of the break and afterward dissect- 
ing the parts freely from the bone. This mode of operating is 
suited to such hard palates as have a thick, soft, mucous membrane. 
By such a mode of operating, and with such character of mucous 
membrane, quite wide chasms may be easily spanned. 

With such mucous membrane, plastic operations will be found to 
answer very well. It is quite easy to get a flap without disturbing 
the periosteum, and such a flap may be twisted on its pedicle with- 
out any special interference with its function. The pedicle, however, 
should be as wide as possible, remembering that the circulation per- 
tains to the basement membrane alone. An objection, however, to 
such operations in the mouth is the difficulty that attends the fixing 
of the flap in its new place. 

The next mode of relieving these defects that may be alluded to 
is that originally suggested by Dieffenbach. This surgeon commends 
the penciling of the edges of the break with tincture of cantharides, 
hoping thereby to excite granulation to an extent that shall fill up 
the cleft. 

Now, while this does very well for small holes, it seldom succeeds 
with the larger. The granulations, having nothing to support them, 
break down before connecting in the middle. 

This defect in the treatment can be remedied, and success almost 
warranted, by the following modification: make a simple obturator 



1028 ORAL DISEASES AND SUBGERT. 

or artificial palate; the mode of doing which is described in the 
following chapter. After fitting this so as to cover accurately every 
portion of the hard palate, it may be removed, and the cleft pared ; 
next touch the parts with cantharides or tincture of iodine, — the 
latter is to be preferred. The plate is now to be replaced, and will 
be found to act most completely as a support to the granulations 
which will be formed. The process of freshening the edges is, of 
course, to be frequently repeated ; but after the first paring the cuts 
may be made from the circle on, and not around, the cavity. 

Uranoplasty. — To Dr. J. Mason Warren seems justly due the 
credit of the conception of this operation. His plan of manipulation 
was as follows. Incisions were first made on either side of the 
cleft down to the submucous cellular tissue, being midway between 
the borders of the break and the alveolar processes, these incisions 
extending back to the extent of the break. Next, using a double- 
edged knife, these flaps were dissected toward the cleft, and, falling, 
were united in the middle line. Another plan practiced by this 
surgeon consisted in dissecting the mucous membrane from the 
edges of the cleft toward the alveolar processes, and, as they were 
thus made loose and pendulous, uniting them along the centre line. 

A modification by Langenbeck on the operation of Warren consists 
in including in the dissection the periosteum, thus taking advantage 
of its osteo-genetic qualities to secure the filling of the break by a 
deposit of bone. 

The use of a gag to keep the jaws separated, both in the opera- 
tion of staphyloraphy and in that of uranoplasty, will be found to add 
to convenience in the operation. The instrument of Kolbe, shown on 
page 207, the author occasionally uses with much satisfaction. A 
means, however, more commonly employed is known as Whitehead's 
Gag and Tongue-Depressor ; this consists of two curved bars, one 
supporting either jaw, kept separated by a ratchet lever ; to the lower 
bar being attached the tongue-holder. A modification of this gag 
(or, more properly speaking, of the Smith gag, which is much like it), 
made by Dr. Louis Elsberg,* of New York, is preferred by many. 

Another form of gag is a very simple, but yet quite effective, 
apparatus devised by Dr. Good willie, shown in Fig. 332 : this consists 
of two arms covered with elastic rubber, with a central screw which 



* A sponge-holder of most convenient form and construction, and of great 
service in operations about the mouth, is known as Elsberg's sponge-forceps. 



PALATINE DEFECTS AND THEIR TREATMENT. 1029 



increases or diminishes the length of the piece as required, 
of this class require, however, to be held in by the finger 
assistant. 

Still another form of this instrument is one devised 
by John Wood, of King's College Hospital, and 
which is used exclusively by Sir Wm. Fergusson in 
his operations about the mouth : this consists of a 
double bar, having rests for the support of the teeth, 
and which are separated on a principle precisely the 
same as that employed with the bivalve speculum. 



Gags 
of an 



Fig. 332. 




The next class of palatine defects which claim our attention are 
such as require for their relief mechanical treatment. This brings 
us to the subject of the obturator, — an instrument whose style, form, 
and manufacture are of the same interest to the surgeon as are those 
of the pessary to the obstetrician. 



CHAPTER L. 



OBTURATORS. 



The instrument, or plate, called an obturator, gets its name from 
the Latin verb obturo, and signifies a something that shall close 
or stop up an entrance or break. Thus, after the operation of tre- 
phining, it is not uncommon to shield the exposed brain against risk 
of accident by fitting a silver plate over the site of the removed bone ; 
and this shield is, to all intents and purposes, an obturator: it closes 
the break in the continuity. 

In the treatment of palatine defects, obturators may be employed 
with the greatest success; the range of their application is really 
wonderful. I have seen one case, at least, where the whole side of 
a face has been so completely restored through such instrumentality, 
that a passing observer would scarcely, I think, have remarked any- 
thing amiss with the wearer. 

In the consideration of the more strictly surgical treatment of pala- 
tine defects, we studied the operations which suggested themselves 
as being the most effective and promising. It is not, however, as 
will be found, every patient who is willing to submit to an operation ; 
and it is not, on the other hand, as we are prepared to understand, 
every case that is fit to be operated upon. To leave either class of 
persons to their fate would be as cruel as it would be unnecessary ; 
it is here, therefore, we may so happily resort to the means known 
as the surgico-mechanical. 

As obturators are to fulfill various indications, so, of course, do 
they vary in form, style, and method of manufacture. The simplest 
obturator is one made to cover a break, more or less extensive, 
in the hard palate proper, — that is, a break which does not impli- 
cate either the alveolar borders or the soft palate. Such an obtu- 
rator holds the same relative position to obturators in general that 
the Physick-Dessault apparatus holds to all apparatus for thigh- 
fractures ; both may be termed principals, and all variations are 
but modifications of these principals: thus, if we appreciate the 
(1030) 



OBTUBATORS. 1031 

style, indications met, and mode of manufacture of a simple obturator, 
we shall understand fully the genius of the instrument, and be 
enabled so to appreciate the mechanism of the piece that we will be 
prepared to diminish or enlarge its capacity pro re nata. 

A patient presents himself, let us suppose, suffering under a de- 
ficiency in the hard palate. We examine the case, and find the 
walls of the break so heavily and solidly indurated that we perceive 
at once that any attempt to pare and bring the parts together would 
be futile. Palato-plasty at once, and naturally, suggests itself, but 
observation of the surrounding parts convinces us that the risks are 
too great for the good promised. Such is a case that not unfre- 
quently offers itself to the surgeon's judgment. Dieffenbaeh, whose 
name is so honorably associated with oral surgery, evidently found 
himself much embarrassed with just such cases, — cases which I 
would here present as the easiest of remedy by use of the obturator. 
It was Dieffenbach, it will be remembered, who suggested the stud 
of india-rubber. Two pieces of rubber the thickness of pasteboard 
were cut, being somewhat larger than the opening to be closed, and 
between these was placed a small round piece ; the whole was then 
securely fastened together by means of waxed thread ; one of these 
pieces was intended to rest on the posterior and the other on the 
anterior surface of the opening ; the small middle piece was for the 
intermediate space. 

A moment's reflection will exhibit the inconveniences as well 
as the more striking faults of such an appliance. The rubber, unless 
it were vulcanized (and, to be so applied, it could not be vulcanized), 
would soon become very offensive. It would act as a continual 
source of irritation, and particularly so far as the posterior base of 
the cleft is concerned. The centre piece, which, to hold the parts 
with any degree of steadiness, would have to fit the opening with 
some degree of accuracy, would, because of the presence of moisture 
and heat, soon expand, thus enlarging the canal. It would be very 
inconvenient to remove for the purpose of cleansing, which cleans- 
ing it would certainly demand daily. 

A case amply illustrative of the inefficiency of this mode of 
treating palatine defects, and, indeed, of the absolute harm resulting 
from it, is recorded by Dr. J. H. McQuillen, in the Dental Cosmos. 
The patient, who had an opening in the palate, the result of syphilis, 
was treated by Dr. Daniel Neall, who employed, in the first in- 
stance, india-rubber as a substance from which to construct an obtu- 
rator. This was cut somewhat in a button shape, being large above 



1032 ORAL DISEASES AND SURGERY. 

and below, and contracted in the centre, thus constituting an ap- 
paratus which was retained in position by resting on the floor of 
the nares, surrounding the orifice. After this had been worn a week 
or two, the patient returned, when it was found quite loose and the 
orifice somewhat enlarged, the rubber having acted as a source of 
irritation and induced absorption. Another apparatus was formed 
from the same material, and, after being worn a week, the orifice 
was found much larger than at the previous meeting. The rubber 
was also found considerably affected by the fluids of the mouth. 
Satisfied that it would not answer the purpose intended, this material 
was abandoned, and a simple obturator of silver was constructed, 
covering the orifice and roof of the mouth. This was found to fulfill 
every indication. 

There is another, a somewhat domestic treatment for these defects, 
which I may here allude to. This consists in stuffing the break with 
cotton or wool. The cotton not unfrequently escapes into the throat, 
or, passing into the nares, it has sometimes produced ozaena by lodg- 
ing in the meatus : quite extensive necrosis of the turbinated bones 
has also been provoked in this way. The practice is not without 
danger. 

A case of a different class, yet belonging to the same category so 
far as treatment is concerned, invites, in connection with the consid- 
eration of simple obturators, a moment's attention. This is the exist- 
ence of a cleft or break associated with subacute or chronic disease, — 
the cases to which we allude as not being fit for operation. 

Some time since, Mr. , a French teacher of this city, had 

necrosis of the palatine arch, the result of venereal disease; the se- 
questrum that came away was quite large, producing a break in the 
continuity of the hard palate at least an inch in diameter, of course 
freely exposing the nares. The result was, as might be anticipated, 
that his vocation as a teacher had at once to be relinquished. 

I saw this case, in consultation with the attending surgeon, about 
a month after the patient had resigned a situation which he held in 
one of our principal private schools, and upon which, up to this 
time, he had mainly depended for his income. The necessities of the 
man were immediate, and any operation for the restoration of his 
speech was out of the question. I had the happiness of relieving 
him of his trouble so perfectly after three days, by the use of an 
obturator, that every time we have since met he has laughingly 
assured me that he speaks much better English than before his 
accident. It is certainly true that he speaks quite as well. 



OBTURATOBS. 1033 

The obturator for these cases consists simply of a metal plate 
that shall fit accurately every part of the hard palate, the regu- 
larity of the arch to be restored by carrying the plate over the cleft 
or break. Such a plate should fit with the greatest nicety, and is 
to be held in place either by bands placed around certain of the 
teeth, or by means of atmospheric pressure. The first plan of fasten- 
ing the piece should be employed when disease is associated with 
the cleft. The latter is well adapted when the break is not too large, 
and where all disease has long since passed away. To make such 
an obturator, first take an ordinary impression-cup, such as is em- 
ployed in taking casts of the mouth. This cup is filled with bees- 
wax, softened before the fire to the consistency of dough. Thus 
prepared, the operator takes his position behind the patient, as recom- 
mended in the operation of staphyloraphy. The cup is now to be 
introduced carefully into the mouth, and carried just so far back as 
will allow of the teeth being included within the arch or rim of the 
cup. This accomplished, cup and wax, in a body, are to be pressed 
firmly up into the roof of the mouth and around the neck of the 
teeth and alveolar border. The patient holding his mouth very 
wide open, the mass is to be removed even more carefully than it was 
inserted. This manipulation, if properly executed, gives us the 
exact impression of the mouth. The next step is to make a model. 
To do this, we take the impression we have just obtained, and, sur- 
rounding it with a rim of paper, the rim to be, say, one and a half 
inches in height, we stir into water the common calcined plaster — 
sulphate of lime — until we have a very thick, creamy paste. This 
paste is poured into the impression, and should be enough to fill 
from the wax, which lies at the bottom, up to the top of the rim. 
The model thus made is not to be disturbed for three or four hours ; 
it must have time to set. 

The next step in the operation is to remove, from about the plaster 
cast we have just made, the paper and wax. This is accomplished, 
first, by heating gently the cup in which the wax lies, which permits 
of its easy removal ; and next by carefully trimming from about the 
necks of the teeth, by means of a knife-blade kept constantly warm, 
the wax which so closely surrounds and imbeds them ; in this way 
the wax may all be safely taken away. The paper is, of course, sim- 
ply to be torn away, and this is done before removing either cup or 
wax. Comparing the face of the model thus made with the mouth 
from which the impression was taken, we shall find we have its like- 
ness to the minutest particular. 



1034 ORAL DISEASES AND SURGERY. 

As the model contains the break in the arch, and it is our intention 
to restore this arch to its original and natural contour, so is it at this 
step in the procedure that we can best secure our object. This, I 
think, is most easily done by taking a little ball of warm wax, and 
filling with it the hole or break in the model. The natural concavity 
of the arch is in this way restored. Of course this is not at all diffi- 
cult, nor is there any guess-work about it, as we have the inclinations 
of all the surrounding parts to guide us, and all we have to do is 
simply to model this wax to the proper curve. 

The cast is finished by beveling the portion which rested against 
the paper ; this beveling to be so done that the greatest diameter of 
the model shall be its base. 

This completes the model to which the obturator is to be made. 

The next step is the preparation of dies.* These are to be made, 
one of zinc, the other of lead ; and the process of getting up such 
casts is precisely the same as that adopted by the moulder. 

Procure a moulding-flask or a circle of tin: a common tin cup, 
with the bottom broken out, answers the purpose well enough. Lay 
the model you have prepared upon the table, the palate face looking 
up. Now place the circle of tin over it, and with some moulder's 
sand, very fine, which you have previously moistened and tempered, 
cover in the model, packing and filling the circle completely. Now 
turn the circle or cup so that the base of the cast looks up. Next 
a penknife-blade or a small gimlet is to be inserted into the plaster, 
and by striking it several light taps the cast will be loosened. It 
is now to be lifted from the sand. Thus we have a mould for a 
metal casting. The next step is the making of such a cast. To do 
this we have only to melt, in any convenient vessel, one or two 
pounds of common zinc, and pour it slowly into the mould. This 
done, let the whole remain undisturbed until completely cold. 

Thus, it is seen, we have prepared, with little or no labor, a cor- 
rect model of the mouth in metal. It is to this zinc model we are 
to fit and adapt our obturator. Now, this latter process is easy or 
difficult, according as one goes about it. One method is to take 
hammer, files, and pliers, and cut, file, and mallet, until the adapta- 
tion is secured. Such a task is almost as hard as was the cleaning 
of the Augean stables; besides, it is next to an impossibility to ac- 

* The model, or even the impression, being handed to the mechanical dentist, 
the obturator can be made, ready to put in place, without further trouble to 
the surgeon. 



OBTURATORS. 



1035 



cornplish the work properly. A second plan, and one which is as 
easy, simple, and interesting as the other is difficult, perplexing, and 
annoying, consists in making a counter-model in lead, between which 
and the model, or male cast, as it is called, the palate or obturator is 
to be struck up. This counter-model is very easily made, as follows : 

Take the zinc cast and lay it upon the table, with the face or pal- 
atine surface looking up ; lay over it the cup or circle, precisely as 
in the case of the plaster model. Now with the sand moistened as 
before, fill up the cup covering in the cast, packing the sand as solidly 
as possible. Next, without disturbing the cup as it rests upon the 
table, take a knife and dig away the sand until you expose the face 
of the cast. You are now prepared to make the counter-model. 
Take a vessel (not the one in which you melted the zinc), and place 
in it two or more pounds of lead ; when melted, pour this over the 
face of the zinc cast, filling up to the very top the hole which you 
have dug out in the sand. When the lead has become cool, remove 
the castings from the sand, and, with a hammer, the two are easily 
knocked apart. 

To make the obturator by means of the dies thus obtained, we 
proceed as follows : a piece of thin sheet-lead is forced with the fingers 
over the face of the zinc cast; with a sharp and delicate-bladed knife 
this lead is cut so as to cover accurately the hard palate, being even 
festooned so as to adapt itself accurately about the necks of all the 
teeth. This palate of lead being thus nicely and correctly fitted to 
the parts, it is taken off the casts and carefully spread. Next it is 
laid on a piece of gold or silver plate, and the outlines distinctly 
marked with cutting forceps ; the shape of the arch, as marked from 
the lead, is then cut from this second piece of metal. The next step 
is the process of annealing, or softening the metal, so that it shall 
be as malleable as possible. This consists in subjecting it to a red 
heat, which may be done in any convenient manner. The mechan- 
ical dentist lays the piece on charcoal, and throws over it, by means 
of a blow-pipe, the flame from his alcohol soldering-lamp. This 
does it very nicely. 

Next the metal is to be taken up, and so bent with pliers as to fit 
the cast tolerably ; it is not, however, at all necessary, in this proce- 
dure, to give one's self much trouble. Next take up the counter- 
model, and lay it carefully over the zinc, — the plate being between 
the two. With a hammer the casts are now to be driven together. 
In this step of the operation it is desirable that we should feel our 
way, — that is, hit the models a few slight taps, and then, taking 



1036 ORAL DISEASES AND SURGERY. 

them apart, see if the plate is going as we want it. If all is right, 
the casts may be driven into each other with all reasonable force. 
If, on the contrary, the plate is not taking a proper direction, it must 
be so inclined by means of the pliers. To complete the finish of the 
plate itself, the festoons, which are to embrace the necks of the teeth, 
should be cleanly cut out by means of the ordinary round file. 

Thus we have an obturator completed. If we place it in the 
mouth, we shall see that we have restored the arch, by our con- 
trivance, to its original condition, at least so far as the purposes of 
speech and mastication are concerned. 

Nothing now remains but to secure the piece firmly to its place. 
And this brings us to the consideration of modifications of the 
instrument. 

If a patient, for whom we had made such an obturator as that 
the manufacture of which has just been described, had certain good 
sound teeth, we might proceed to fix the piece in the mouth as fol- 
lows. Going back to the plaster model, we would fit around such 
teeth as might seem to us best adapted to our purpose, delicate bands 
of metal — gold should always be preferred ; these bands should fit 
the teeth with great accuracy, and should be fixed to their places 
while the obturator is lying on the model. Take next a particle of 
wax, and stick the plate and bands together. Now carefully lift all 
from the model, and set in plaster. This last manipulation is accom- 
plished by laying the piece on charcoal, and pouring over it, the wax 
alone excepted, the creamy plaster before alluded to. When this plas- 
ter sets, the wax is taken away, and there is exposed a small portion, 
both of obturator and bands. These parts are to be soldered together. 

This last process finishes the piece for the mouth. In placing it 
in position, we have only to slip the bands over the teeth, and we 
will find that it is held with all security. 

Another plan of securing the apparatus to the mouth is by means 
of atmospheric pressure. To accomplish this, a cavity is to be made 
in the piece. This is done by placing on the plaster model, before 
making the castings from it, a piece of wax: its shape may repre- 
sent, in diameter and thickness, the ordinary half-dime. Or perhaps 
we cannot find a surface on the arch for a suction of such size and 
shape ; if so, it may be lessened, or the shape maybe modified so as 
to suit any case. What we want is a cavity in the plate ; the size 
and location are not of great consequence. Such a piece of wax 
will, of course, be represented by zinc in the casting, and by a 
depression in the counter-cast. In forcing the plate between the 



OBTURATOBS. 



1037 



dies, the portion represented by the wax is thrown up ; thus, when 
the plate is in the mouth, a cavity is formed. The obturator is held, 
in this case, by making an air-pump, as it were, of the tongue, and 
sucking the air from the cavity. I have seen obturators, thus de- 
pendent on atmospheric pressure for fixedness, held so tightly that 
it required considerable force to effect their removal. The principle 
is the same as that employed for holding artificial teeth in place. 
The modus operandi will be perfectly understood at a glance by 
looking at any set of teeth made for the superior jaw. 

Another modification of the obturator is that in which the piece is 

Fig. 333. 




held to its place by a bulb or rim, which passes into the cavity of 
the break. This adapts the instrument to such cases as have neither 
teeth nor site for suction, where, for instance, disease has destroyed 
the whole of the hard palate, leaving alone, as boundaries of the 
cleft, the alveolar processes and soft palate. Such an obturator and 
the character of cleft for which it is adapted are happily and truth- 
fully exhibited in the accompanying drawings. Fig. 333 represents 
the mouth, Fig. 334 the obturator. This case, and others which 
represent various modifications of the apparatus, are from life, having 



1038 



ORAL DISEASES AND SURGERY. 



Fig. 334. 




occurred in the practice of prominent dentists. The models shown, 
with an accompanying history of the cases, were presented to the 
Pennsylvania Association of Dentists, at a meeting held by that 
Society.* 

" The first case, as seen in Fig. 334, from the practice of Dr. 
McGrath & Son, was that of a female over fifty years of age. In this 

instance the fissure was confined 
to the hard palate, and was un- 
doubtedly the result of syphilis. 
Of the history of this case, all that 
could be obtained was such as was 
derived from answers to indirect 
questions which were put to her. 
They learned that the defect was 
the result of a disease which com- 
menced as sore throat and con- 
tinued its ravages for over three 
years before it was arrested ; this, 
together with the appearance of 
the pharynx and uvula, — they be- 
ing covered with cicatrices, the re- 
sult of old ulcers, — left them without any doubt as to the true nature 
of the complaint. The parts which had been destroyed during the 
progress of the disease were the palate-bones and the palatine pro- 
cesses of the superior maxillaries (making an opening into the nose 
nearly two inches in length and one inch in breadth), the turbinated 
bones (with the exception of the middle one on the left side, which 
is represented in the cut as projecting from the side of the cavity), 
and the vomer, producing an enormous irregularly shaped cavity, 
extending as high up as the nasal bones, which latter, however, 
bore no traces of ever having been affected by the disease. The 
patient, in order to prevent the passage of the food into the cavity 
during mastication, had been in the habit of filling the opening 
with a fold of muslin, which answered the purpose to a certain ex- 
tent ; the velum was entire ; the patient had also lost all the teeth 
of the upper jaw. 

" The kind of obturator employed in this case was simple and 
uncomplicated in its mechanism, Fig. 334. A plate was made to fit 
accurately to the alveolar ridge, extending about one-eighth of an 




* Report by Geo. T. Barker, D.D.S. 



OBTURATORS. 1039 

inch beyond the posterior margin of the opening ; also passing in to 
a distance of nearly an inch, and fitting as closely as possible to the 
anterior and lateral sides of the cavity. The object of this latter 
arrangement was to render the plate firm in its position. From the 
posterior margin of the opening, and extending forward about half 
the length of the alveolar ridge, was a fold of mucous membrane 
projecting inward and upward, over this fold ; that portion of the 
plate which was opposite to it was bent. This, together with the 
suction obtained by the plate fitting closely to the alveolar ridge, 
enabled the wearer to keep it in its place. The opening was then 
covered, by soldering to this a second piece of plate, so fashioned 
as to represent as nearly as possible the form of the lost palate. 
The object in not extending the plate into the cavity on the poste- 
rior edge of the opening was to prevent a lodgment for the nasal 
secretions, which by their accumulation would prove offensive to 
the patient. The artificial teeth were then fastened in their proper 
position, and the apparatus was complete. This obturator the 
patient had been wearing for about three months ; it remained in 
place and fulfilled the office of mastication as well as any ordinary 
suction plate in a mouth where no defect of the palate exists. 

" The second case, Fig. 335, was also that of a female, but the 
fissure was confined to the soft palate. This, as in the former case, 
was the result of syphilis. The fissure extended from the posterior 
opening of the nares through the velum to the palate-bones, and was 
nearly an inch in breadth. The uvula was entirely gone, as well as 
the lateral half-arches, and along with them the palato-pharyngei 
and constrictores isthmi faucium muscles. In this case deglutition 
was impaired to a great extent ; the food would pass into the nares, 
and the fluids would also pass into the nasal cavity and out through 
their anterior openings. The disease had not confined itself to the 
palate, but, extending to the nasal organs, had completely destroyed 
their internal structure, as well as a portion of the nasal bone, to 
such an extent as materially to change the external shape of that 
organ. The obturator, Fig. 336, constructed for this case, was of 
one piece, and made to cover the hard palate completely, extending 
from the central incisors to the posterior wall of the pharynx, and 
passing a short distance beyond the edges of the opening on each 
side. The plate was made to press firmly against that portion of 
the soft palate which remained, yet not so firmly as to be the cause of 
irritation, the edges of the plate being slightly bent downward for 
the same reason ; the object being to prevent the possibility of the 



1040 



ORAL DISEASES AND SURGERY. 



soft parts being drawn above the palate, which would afford a com- 
munication with the nares. The posterior edge of the obturator was 
bent downward at a right angle with the body of the palate, and 
curved so as to form with the posterior wall of the pharynx an oval 
opening sufficiently large to permit the patient to breathe freely 
through the nostrils. In the act of deglutition, the muscles would 
contract and press against this portion of the plate, thereby cutting 

Fig. 335. 




off the communication with the nares. To this plate were attached 
three artificial teeth, — two lateral incisors and one molar, — the 
whole being retained in position by means of clasps around the 
teeth. 

"This obturator the patient had been wearing a little over two 
months, and, like the former one, has proved successful, deglutition 
being restored, and the speech considerably improved." 

Dr. T. L. Buckingham, Professor of Chemistry in the Pennsyl- 
vania College of Dental Surgery, presented the following cases : 

" The first case," he said, " he had anything to do with was that 



OBTURATORS. 



1041 



of a gentleman who had an opening through the hard palate, in the 
centre of the arch, about as large as a ten-cent piece. This gentle- 
man had worn an obturator with a sponge attached to it, made in 
the following manner: a plate was struck up to fit the roof of the 
mouth, and a piece of sponge was sewed upon the palatine surface, 
to fill the opening, and to hold the plate in its place. Some of the 
objections to this obturator were that the opening became enlarged 
from the absorption occasioned by the pressure of the sponge upon 
the sides of the cavity ; it would also become very offensive, and re- 
quire frequent removal. In this case a plate was struck up to fit 
the mouth, and attached to the teeth by means of clasps. This 

Fig. 336. 




simple appliance answered better than any other that had been made 
for him. 

" The second case was that of a gentleman who had an opening 
into the left antrum, at the point where the second bicuspis and the 
first molar had been, but on the outer surface of the alveolar ridge, or 
rather where the ridge had been — for the alveolus was entirely ab- 
sorbed opposite the opening, which was about half an inch in length 
by a quarter in width. The nasal bones were diseased, which caused 
an almost intolerable odor. 

" He made for this case a small obturator to close the opening. 
This was left open at the top, to allow him to place in it a small 
portion of chloride of lime. His intention was to correct, if possible, 
the offensive smell, but the patient did not live long enough to give 

65 



1042 



ORAL DISEASES AND SURGERY. 



it a fair trial ; lie remarked that while any of the chloride of lime 
remained in the obturator there was no unpleasant smell ; but, unfor- 
tunately for the experiment, the gentleman had lost nearly all the 
sense of smell, and therefore could not tell when it had evaporated. 

" He made for this case an upper set of teeth, to which the obtu- 
rator was secured, it being held in position, to a great degree, by 
the plate and teeth. 

"In the two preceding cases the voice was not altered when the 
appliances were in the mouth. 

" The third case was that of a gentleman who, on a previous occa- 
sion, had a tumor removed which covered a portion of the posterior 



Fig. 837. 



M 



IliiP 

v ? H 




surface of the hard and the anterior surface of the soft palate. The 
surgeon, on its removal, had divided the velum and uvula, so that the 
case resembled a congenital deformity. The attempt had been made 
twice to bring the soft parts together again by a surgical operation, 
which had failed. 

"Fig. 337 shows the appearance of the parts very clearly, — the 
letters A and B showing the thickened muscles as they hung down 
on the side of the pharynx. 

" He made for this case an obturator, Fig. 338, the plate of which 
covered the w T hole of the roof of the mouth, with a bulb attached, 



OBTURATORS. 1043 

extend up into the posterior nares and well back toward the antero- 
posterior walls of the pharynx, leaving but a small space between 
them. This obturator enabled the patient to eat and drink without 
annoyance ; without it food would pass into the nares and occasion 
much inconvenience. It also greatly assisted his voice, as many of 
his words could not be understood when it was not worn, but he 
could articulate them with great distinctness when it was in place. 

Fig. 338. 




Dr. Buckingham remarked that he had been more successful in re- 
storing the voice in this case than in any other he had treated, and 
attributed it to the fact that this person, having once had his voice 
perfect, was always endeavoring to speak as he had formerly done, 
while in the congenital cases they did not try to overcome this 
difficulty. 

" The fourth case was that of a lady who had an opening in the 
anterior part of the hard palate, a little larger than a ten-cent piece, 
and also a small one exposing the left antrum. All the teeth in the 
superior arch had been removed, and absorption of the alveolar 
process, opposite the smaller opening, had progressed to such an 
extent as to present at that point a deep depression ; the remaining 
part of the alveolar ridge had not been absorbed more than is usual 
where the teeth have been lost. 

" Fig. 339 shows the appearance of the different parts, C repre- 
senting the smaller opening, and D the larger one ; between these 
two points was the depression referred to. 

11 This lady had never worn any mechanical appliance, but had 
been in the habit of closing the larger opening with loose cotton or 
pieces of linen. Without having it filled, she could scarcely be 
understood when speaking. He made for this case, first, a plain 
plate to extend over both the openings, but not into them ; upon 
this plate, at the point where the process had been absorbed, he 
arranged wax so as to restore the alveolar ridge to its natural full- 



1044 ORAL DISEASES AND SURGERY. 

ness. By using the plate with the wax attached for a mould, he 
was able to obtain metallic dies. A second plate was then made 
to fit over that part of the first one which was covered by the wax ; 
these two plates were then soldered together. The object in forming 
a double plate was to fill up that part where absorption had taken 

Fig. 339. 




place, so that the plate when worn would resemble the roof of the 
mouth, and not be deeper on one side than on the other. 

"This obturator was very successful: the voice was much im- 
proved, and she could eat and drink as well as persons ordinarily 
can who wear upper sets of teeth ; and, what was more remarkable, 
she could wear it without springs or any assistance whatever to 
retain it in position. 

" He stated that he hardly knew whether his fifth case should 
come under discussion at the present time or not, as it could hardly 
be termed a palatine fissure ; but, from its exceeding interest, he 
would now present it. 

"A gentleman was handling a gun loaded with buckshot, when 
it was discharged in his hands. The gun being pointed toward his 
head at the time, the load struck him at the angle made by the ramus 
and the body of the inferior maxillary on the right side, passing up- 
ward and outward on the opposite side of the face. It must have 
been a terrible wound, and should, from the representation given, 
have caused almost instant death. He, however, recovered, after 



OBTURATORS. 



1045 



being confined to his bed for more than a year, and during that time 
he had to be fed with a spoon. The only way he could eat or drink 
was to lie on his back and let the food run down his throat, and it 
was a long time before he found he could swallow. 

" The teeth in the upper jaw were all gone, excepting the left second 
molar and wisdom tooth ; both antra were fully exposed, the remain- 
ing roof of the mouth being left almost flat. The lower jaw-bone was 
gone on the right side, from the second bicuspid back, and also the 
condyloid process ; but about three-quarters of an inch of the coro- 
noid remained, which was drawn in so as to partially cover the roof 
of the mouth. The molar teeth were lost on the left side, and also 

Fig. 340. 




all on the right side from the symphysis. In taking hold of the 
lower jaw it could be moved either backward, forward, or laterally, 
to a considerable distance. 

" Figs. 340 and 341 show this case — the letters A and B the open- 
ings in the antrum, and C the end of the lower jaw-bone. The dis- 
tance between the points A and C, when the mouth was closed, was 
just two inches. 

" This gentleman had been wearing a partial set of upper teeth 
which had been attached to the molars, but the clasps of the artifi- 
cial teeth had loosened them, and it was therefore necessary to re- 
place the piece of work with a set that could be supported in some 
other way. 



1046 



ORAL DISEASES AND SURGERY. 



Fig. 341. 




"This was the most difficult case he had ever treated. One of 
the greatest obstacles he encouDtered was the obtaining- of a cor- 
rect impression. To accomplish 
this, he first filled the antra with 
loose cotton, to prevent the wax 
from passing into them ; he then 
took as good a wax impression as 
he could of both the upper and 
the lower jaws ; from these he 
made impression-cups to be used 
in taking the plaster impressions. 
There was very little difiBculty in 
obtaining an impression of the up- 
per jaw with plaster (the antra 
being filled with cotton as before), 
but it was far more difficult to 
take a good one of the lower jaw. 
The distance from the points of the teeth down to the point marked 
C, as shown in Fig. 340, was so great that when any material was 
forced down to take the impression, it was almost impossible to re- 
move it from the mouth without altering it so much as to render it 
of no value. After several trials, he succeeded in getting a very 
good one with plaster. It had to be broken before its removal from 
the mouth ; but, by carefully putting the pieces together, a good 
cast was obtained. 

" He then made a plate to extend over the roof of the mouth and 
cover both of the cavities opening into the antra; on this plate he 
arranged wax, bringing it down as far as the alveolar ridge should 
have been ; then made a metal cast and struck another plate to fit 
over the first, soldered them together, and placed upon these single 
gum teeth as he would have done had there been no more absorption 
than is usually found in upper cases. 

" There was nothing peculiar in the formation of the lower case, 
except that the teeth had to be very long on the right side (for this 
a block was made), and the plate was not allowed to extend farther 
back than to the position once occupied by the second bicuspid tooth. 
The under teeth were put in more for the purpose of attaching 
springs for the support of the upper ones than for use. 

"He could not say what success had attended this case, as the 
gentleman left the city immediately upon their insertion, and he had 
not seen him since that time." 



OBTUBATOES. 1047 

Other cases of equal interest are found in the report ; but, as they 
are unaccompanied by models, I omit them. 

A material for obturators is fast winning its way to professional 
favor in the article known as vulcanite. This is the base now so 
extensively used in the manufacture of sets of teeth. Its merits 
and demerits are widely discussed in all the dental publications of 
the day, and from these journals everything pertaining to it may be 
gleaned. The advantages claimed for it are : its cheapness, its 
lightness, its capability of being moulded into the most irregular 
positions, and its resemblance in color and feel to the natural parts. 
The objections are its liability to decompose and become offensive. 
The manipulation of the material is so easy that the surgeon at- 
tempting the manufacture from it of surgical appliances would give 
himself a source of recreation rather than work. To make an ob- 
turator from vulcanite, you take an impression of the mouth in wax 
and make from it a plaster model precisely as before described. 
Prepared gutta-percha is now moulded over this model to the form 
required. Plaster is next run over this first model, the gutta-percha 
plate being between. The model and counter-model thus made are 
separated, and the place of the original plate supplied with fresh 
vulcanite. The models are now put together, and the vulcanite 
between subjected to pressure. The whole is then placed in an ap- 
paratus termed the vulcanizer, and, filling this with water, the tem- 
perature is raised to about 325 degrees. When taken from the steam- 
bath the plate is found to be as hard as bOne. The last process 
consists in the polishing of the piece; this is a simple manipulation, 
and requires only one or two files, a burnisher, and some patience. 

M. Desirabode, a French surgeon, proposes a palatine obturator 
for congenital fissure of the palate, by which he thinks the sides of 
the alveolar border may be so approximated as to favor a union of 
the divided parts. It consists of a platina plate fitted to the vault 
of the palate and fastened to the teeth by means of three clasps 
soldered to each side, so as to cap the canine teeth, the bicuspid, 
and two of the molar teeth, bent upon the alveolar border in such a 
manner as to maintain the whole pressure. After the plate with these 
appendages has been well adapted, it is to be divided from before 
backward along the median line, and then a piece removed from either 
side so that the two edges may be separated about half an inch from 
each other. The two plates are now united by means of a thick and 
resisting band of caoutchouc, made fast by riveting. The plates thus 
united form a smaller obturator than the plate before it was divided, 



1048 ORAL DISEASES AND SURGEBY. 

so that it can only be applied by putting the caoutchouc on the 
stretch, which is effected by means of two sticks so contrived as 
to force the plates asunder. After the plate is properly adjusted, 
these are removed, when, by the contraction of the caoutchouc, the 
sides of the alveolar borders are gradually approximated. 

This contrivance of Desirabode looks very plausible, but, unfor- 
tunately, all experience is against its employment. 

In the first place, to correct by pressure a fissure in the hard 
palate implies the very earliest use of such force. A child is five 
or six years old before its first dentition is properly completed; 
and even at this period one would not dare to apply any such 
apparatus, because of the physiological process of absorption which 
has already commenced in certain of the teeth. Then if, on the con- 
trary, he meant his instrument to apply to a more advanced period, 
he would have to wait until at least the sixteenth year, as before 
this age the fangs of the molars are not perfected. The bones by 
this time have, as a matter of course, become much less amenable 
to treatment. And again, even besides this, as I know from practical 
teachings, his apparatus would in less than a week's time produce 
such periosteal trouble about the alveoli that no human being would, 
or could, bear the continuance of the pressure; or, even admitting 
there should be found a patient heroic enough to bear the treatment, 
the apparatus would have its usefulness destroyed in less than two 
weeks by the teeth, to which it was attached, coming away. In 
other words, the instrument is useless, because the teeth, being the 
weaker and more yielding, would give way first. 

In Liston and Mutter's Surgery is an engraving of an obturator 
made to supply the loss of both hard and soft palates. The con- 
trivance, which is a simple plate such as has been described, is seen 
to extend from the teeth back to the fauces. Attached to the back 
portion of the plate representing the soft palate is a metal pendulum 
working on a hinge ; this pendulum is much better omitted, for, 
while it cannot possibly answer any useful purpose, it must certainly 
be much in the way. In making so extensive an obturator, it is not 
to be forgotten that the part which represents the soft palate is to 
be given the double curve which is seen on looking into any healthy 
mouth. To get the impression for such an obturator, we have to 
employ a very deep impression-cup. 

Dr. E. Wildman, of the Pennsylvania College of Dental Surgery, 
kindly furnishes me with a description and cuts of a case, which, as 
a study, will well repay attention. The patient I have myself seen. 



OBTURATORS. 1049 

Fig. 342 will convey an idea of the external appearance of the 
patient, but not fully, as the whole upper lip was cicatrized, and 
the left cheek depressed near the border of the cavity. 

Fig. 342. — The Face without Nose. 




" In May, 1863, a young man," says Dr. Wildman, " aged twenty- 
six years, presented himself for the purpose of having an appliance 
made to repair a loss sustained by disease. Upon removing the 
black patch which he wore upon his face, and the cotton with which 
the cavity was filled (without the latter he could not articulate a 
word), I found that the entire external nose was gone, — that the 
nasal bones, the nasal processes of the superior maxillary, also a 
large portion of their palatine processes, the approximal parts of 
the palatine processes of the palatine, and the turbinated bones, had 
been destroyed. The soft palate, the uvula, and the tonsils were 
uninjured. 

" In looking into the nasal cavity, the walls of the antrum on the 
left side were found deficient, and ends of the roots of the incisors 
exposed and decayed. The tongue was visible through the opening 
in the palatine arch. The size and shape of this orifice are repre- 
sented by the outer central line in Fig. 343. 



1050 



ORAL DISEASES AND SURGERY. 



11 Although desirable, it was deemed unsafe to remove the diseased 
roots, owing to the yielding nature of the superior maxillary bones. 

Fig. 343. — Internal View of Superior Arch. 




The disease appeared to be arrested, and the parts in a sufficiently 
healthy condition to warrant the application of the substitute ; and 
time has verified this, as, with the exception of the exfoliation of a 
small scale from one of the superior maxillary bones, about nine 
months since, no change has taken place up to this date. 

" The first step in the operation was to procure an impression that 
would enable me to make a perfect model of all the parts involved, 
and their surroundings, in their relative positions. For this purpose 
plaster was best adapted, but its use was precluded by the acrid se- 
cretions in the nasal cavity ; wax and paraffin was considered the 
best substitute, and used. Owing to the rigidity of the upper lip, I 
was unable to use the ordinary impression-cup with success, and 
was obliged to take a rough impression of the palatine arch, from 
which a model was made, and a metallic impression-cup swaged. 

"A sufficient quantity of paraffin and wax was placed in warm 
water, and, with an assistant to keep it at the proper temperature, 
the mode of procedure was as follows: a proper quantity of the com- 
pound was placed in the cup, introduced into the mouth, and pressed 
up firmly against the arch ; the part forced into the palatine fissure 



OBTURATORS. 1051 

was at the same time pressed with the finger, introduced through 
the nasal cavity, so that it should give an accurate impression of its 
lateral borders. A groove was then cut in this to serve as a key, 
and, after oiling it, a piece of the compound was introduced through 
the orifice of the nasal cavity, and passed down to make the impres- 
sion of the floor of the nasal cavity. When sufficiently hard, it was 
carefully removed, the upper surface trimmed, placed in cold water 
to give it its greatest firmness, then introduced into the cavity, and 
pressed into its proper position. The metallic cup containing the 
impression of the palatine arch was then removed. The next step 
was to take an impression of the sides of the cavity, then the top, 
using a curved wooden spatula to press the compound in proper posi- 
tion, being careful to mark or key the parts that came in contact, 
and have their surfaces oiled, to prevent adhesion ; and also that the 
pieces should be thinner in front than in their posterior parts, so that 
when the four pieces forming the impression of the base, sides, and 
top were in their proper position, they would leave a tapering cavity, 
with its largest diameter at the front orifice. Into this orifice was 
forced a plug or cone of the compound, filling it completely; in the 
front of this piece were inserted pieces of match sticks, to cause it to 
adhere to the next piece or mask. The head was now thrown back 
to nearly a horizontal position, wet tissue-paper was placed over the 
eyebrows and lashes, the face oiled, and plaster mixed thick was 
batted on with a brush. When set, this was removed, drawing with 
it the central plug or cone ; the different parts were then carefully 
removed, and thrown into cold water to give them a consistency to 
bear handling without danger of injury. On this central cone all 
the parts were placed in their proper position, and the impression of 
the palatine arch was adjusted in its proper place. From this a 
plaster model was made, giving the upper part of the face, cavities, 
palatine arch, all correctly in their relative positions. 

" Of the different substances — leather, wood, wax, metal enameled, 
and porcelain — used for making artificial noses, I gave the preference 
to hard rubber in this case, on account of its rigidity, strength, light- 
ness, and less liability to injury by accident.* 

" To prevent derangement, it was necessary to make the appliance 
as simple as possible; it consisted of two pieces: the external nose, 

* Aluminium, the author thinks, will eventually be much used for all this 
class of operations: it is light, soft, easily worked, and may he beautifully en- 
ameled. When corrugated or bent into the form of a nose, it is as resisting as 
eighteen -carat gold-plate. 



1052 



ORAL DISEASES AND SURGERY. 



septum, and floor of the nasal cavity constituted one, having a pro- 
jection passing downward into the palatine fissure, as represented in 
Figures 343 and 344, A; and the other, the obturator B, Fig. 345, 
with a projection rising upward into the palatine fissure. These 

Figs. 344 and 345. — Nose with Attachments. 




projections were made hollow, so that when the two parts were 
placed together, as in Fig. 344, there would be a cavity or box 
wherein the attachments could be placed. 

"Models were made of the compound of paraffin and wax, which 
were strengthened in the weaker parts by imbedding small strips of 
metal in their substance to give sufficient firmness to admit of the 
necessary handling without injury. The model was applied to the 
patient, and the nose trimmed" so as to harmonize with his features. 
They were then imbedded in plaster in the usual manner for vulcan- 
ite work, with the exception that a stout curved wire passed through 
the artificial nasal cavities, extending beyond their borders, to give 
strength to the rods of plaster forming these cavities in the matrix, 
and thus to prevent their fracture in packing. 

" This appliance was vulcanized four hours, consuming one hour 
in attaining 280° Fahr., at which point it was held one hour, and 
occupying the third hour in elevating the temperature to 320°, where 
it was retained one hour. The work was rather overdone, but not 
so much so as to injure it. 



OBTURATORS. 



1053 



" The two pieces were retained in position by a staple and slide- 
bolt. In the recess of the part of the floor of the nasal cavity pro- 
jecting into the palatine fissure (A, Fig. 344) was inserted a gold 
staple. In the recess of the projection of the obturator passing into 
the palatine fissure (B, Fig. 345) were the gold catch and shield of 
the slide-bolt. The object of this shield was to prevent any foreign 
substance entering the slot and obstructing the movements of the 
bolt, also to give a base of support to the catch. The rectangular 
upright of the catch was soldered to the shield, passed through it 
and a longitudinal slot in B, and securely fastened to a rubber slide 
inlaid longitudinally, and moving freely in the lingual surface of the 
obturator. On the anterior end of this slide was a small rounded 
projection, which enabled the patient, when the two parts of the 
appliance were placed in their proper position, with the point of a 

Fig. 346. — The Face with Nose. 




finger introduced into the mouth, to force the slide backward, thereby 
to pass the catch into the staple and firmly secure the apparatus, or, 
by drawing the slide forward, detach the parts when desirable to 
remove them. 



1054 ORAL DISEASES AND SURGERY. 

"The external nose was painted with oil color, to give it as nearly 
a flesh tint as possible, although this is not attainable upon an 
opaque ground. Flesh being translucent, a true imitation can only 
be made upon a translucent ground. 

"The apparatus was introduced on June 30, 1863, giving to 
the patient great satisfaction and comfort. His appearance was 
much improved, as may be judged by comparing Figs. 342 and 346, 
which were engraved from photographs. He breathes freely through 
the nose, and speaks with ease; the only imperfection in his speech is 
a nasal twang, and this is less now than when the instrument was 
first applied. The obturator at first extended too far back, and caused 
some irritation of the velum : this defect was readily remedied. 

11 The operation proved entirely satisfactory, with two exceptions: 
first, the color of the nose was not as natural as desirable, for the 
reason already stated ; second, in deglutition and speech, when the 
tongue pressed forcibly against the posterior part of the obturator, 
an unpleasant vibratory movement of the apex of the nose was 
noticeable. This could have been remedied by an elastic attach- 
ment coupling the two parts of the apparatus, but this mode was 
objectionable by reason of its producing constant pressure upon the 
delicate parts, and thereby endangering absorption. A safer plan 
was adopted by inserting a small steel pin in the nose as near as 
possible to its apex, to which was attached the bridge of a pair of 
spectacle-frames, these being retained in position by an elastic cord 
attached to the bows and passing around the head. This arrange- 
ment answered the double purpose of counteracting the vibratory 
movement, and the bridge of the frames concealing the upper part 
of the joint where the nose came in contact with the face, which 
was most conspicuous. 

" This apparatus is worn with ease and comfort by the patient." 

The obturator, although employed by the ancient Greeks, and by 
every succeeding generation of civilized men, seems to have attained 
to its wonderful completeness only in our own age. Before the 
time of Ambrose Pare, the appliances were all of a temporary 
nature, if we except mention of one suggested by Petronius, in the 
sixteenth century, although whether this surgeon ever really made 
such a plate as he described, we are not informed. To Pare, how- 
ever, we are indebted for a written description of the metal obturator, 
crude, without doubt, but embracing the principles of the present 
instruments. " Made," says this surgeon, " like unto a dish in 



OBTURATORS. 1055 

figure, and on the upper surface, which shall be toward the hair, a 
little sponge must be fastened, which, when it is moistened with the 
moisture distilling from the brain, will become swollen and puffed, 
so that it will fill the concavity of the palate, that the artificial 
palate cannot fall down, but stand fast and firm as if it stood of 
itself." 

Garangeot, in 1115, made an advance on the idea of Pare, — al- 
though, it must be admitted, a very slight one. He describes his 
instrument as having a stem in the form of a screw, upon which 
ran a nut. To make use of it, he cut a piece of sponge in the form 
of a hemisphere, with a flat surface ; through this sponge the stem 
was passed, the nut holding it in place. When about to introduce 
it, he wet the sponge, then squeezed it dry, and forced it through 
the aperture or break. 

After the period of Garangeot, no special advances seem to have 
been made until 1828, when obturators were constructed by a Mr. 
Snell, prepared on casts, which were correct representations or im- 
pressions of the special cases. In a monograph published by this 
surgeon, he says, "My method of constructing an obturator is with 
a gold plate, accurately fitted to the roof of the mouth, extending 
backward to the os palati, or extremity of the hard palate ; a part of 
the plate, about an inch in length, being carried through the fissure. 
To that part of the plate which answers to the nasal fossae are sol- 
dered two plates, meeting in the centre and carried upward through 
the fissure to the top of the remaining portion of the bones, to which 
it should be exactly adapted, and made to the natural shape of the 
nasal palatine floor: thus the fluids of the mouth will be carried 
backward into the fauces. A piece of prepared elastic gum is next 
attached to the posterior part of the plate where the natural soft 
palate commences, extending downward on each side as low as the 
remaining part of the uvula, and grooved at its lateral edges to re- 
ceive the fissured .portions of the velum : a movable velum is placed 
in the posterior centre of the elastic gum. That these may partake 
of the natural movements of the parts during deglutition, a sponge 
is affixed behind them, one end of which is attached to the posterior 
and anterior surfaces of the principal plate, and the other end rests 
gently against the posterior face of the india-rubber ; this keeps it 
always in close apposition with the edges of the fissure during 
deglutition. 

" It is requisite to mention," he says, " that the elastic gum 
should be placed in a gold frame, and not merely fastened to the 



1056 



ORAL DISEASES AND SURGERY. 



posterior part of the plate, as it would shrink up by remaining in 
the mouth. This frame should pass round its edges only, leaving 
the centre upon, etc." 

In 1845, Mr. Stearn, a surgeon of London, conceived the idea of 
an obturator, the principle of which has been brought to great per- 
fection by Dr. Norman Kingsley, of New York.* This appliance, 
as made by Mr. Stearn, consisted of a gold plate fitted to the hard 
palate, having attached to it, by means of two spiral springs, an 
artificial velum of elastic rubber, consisting of a body, wings, and 
grooved edges, to receive the margin of the cleft. The conception 
of this obturator reflects great credit upon Mr. Stearn, an honor 
which Dr. Kingsley may feel it no detraction to share with him. 

The perfected instrument of Dr. Kingsley, though differing greatly 
from that of Mr. Stearn, consists likewise of a body with mova- 
ble wings. These wings, made of soft rubber, fill up the break in 
the soft palate, being moved by the lateral remnants of the defective 
parts. 

With respect to this obturator, so much experience seems to have 
accumulated that its great usefulness can no longer be doubted. 

Fig. 347. 





Fig. 347 is here again introduced as a study in mechanical appli- 
ances. This figure represents the patient as first seen by the author. 



* Dupuytren, the eminent French surgeon, is not, it seems to me, without 
some claim to a share in this invention : his idea, however, was very crude. 



OBTURATORS. 



1057 



Fig. 318, although not taken from the case, is yet wonderfully 
correct as a likeness after treatment of the lip, as described and 
illustrated on pages 988 and 989. 



Fig. 349 is from a photograph 



Fig. 349. 




Fig. 350. 



taken after treatment of the case 
was completed by adaptation of 
an artificial nose, which, with the 
assistance of the ingenious surgical 
artist, Mr. Kemble, was prepared 
for her. In this case, the nose is 
temporarily employed in anticipa- 
tion of a more promising condi- 
tion for restoration of the organ 
by operation. The effect is even 
better than is shown in the photo- 
graph, the nose having since been 
elaborately painted by an eminent portrait-painter.* 

Fig. 350 represents an artificial nose, together with a common 
manner of holding the piece in place. In employing springs, A, A, 
as here shown, great care is to be ex- 
ercised that pressure be so applied as 
to insure if possible against an irrita- 
tion which is apt to result either in 
inflammation or absorption of the 
tissues, thus in a double direction 
rendering the piece useless. Better, 
however, than the upper spring for 
fixing the piece is the use of a pair of 
spectacles ; these, through the employ- 
ment of an elastic band passed around the head, not only prevent all 
motion on the part of the artificial nose, but also conceal the line 
of break. The author is satisfied that the use of the spectacles is 
the best means of fixedness yet devised. 

In gentlemen wearing whiskers and moustache, the lower spring 
is also to be replaced by means of a delicate silver wire painted the 
color of the beard, and kept tense by relation of the two ends through 
the elastic bandage, concealed by the hair as it passes around the 
head. 




* The cut differs from the photograph only as parts aside from the seat of 
operation are concerned, it being necessary to prevent a recognizable likeness. 

66 



CHAPTER LI. 

RESECTIONS OF THE MAXILLARY BONES. 

The history of experimental surgery upon the bones of the face 
constitutes one of the most interesting of the chapters in surgery. 
The formation upon and within these bones of such diseases as 
seemed to make desirable their removal, necessarily directed, from a 
comparatively early period, the attention of surgeons to the feasi- 
bility, propriety, and promises of such operations. 

It is not at all unreasonable to infer that surgery gained its first 
lesson in this direction by observing, through the results of acci- 
dents, how extensive could be an injury done to these parts without 
fatal, or, indeed, even threatening consequences. Hence, as early 
as 1693, Acoluthus, a surgeon of Breslau, attempted the removal of 
a portion of the upper jaw for a tumor, in which operation he suc- 
ceeded very satisfactorily. Jourdan, according to his translator, 
removed, at various times during his century, portions of the jaw. 
To Dr. Jameson, an American surgeon, however, most are agreed, 
belongs the credit of having made the first complete resection or 
removal of the upper jaw, — this having been done in 1820, although 
to Lizars, of Edinburgh, belongs the higher credit of having first sug- 
gested the possibility and advantage of the operation. In 1824, four 
years later, Dr. David Rogers, of New York, resected both superior 
maxillae. Afterward this was attempted by Lizars, and in the same 
year by Gensoul, of France. After this the operations may be 
considered as having become commonly recognized, surgeons of 
ability performing the various sections throughout England and 
France, and especially in the United States. 

While the operation of resection has been frequently performed, 
it cannot but surprise the surgeon of to-day to notice how slowly its 
lessons were learned. At present it is practiced with little prelimi- 
nary caution, being esteemed an operation that may be performed 
with really little danger to the patient, and even without much 
damage to the appearance. Formerly, and, indeed, not very far 
back, it was considered only safe to ligate, as a preliminary step, 
(1058) 






RESECTIONS OF THE 3IAXILLARY BONES. 1059 

the primitive carotid artery; and when, as experience advanced, 
this was seen not to be a necessity, the actual cauterants were 
always held in readiness, a practice which, much to the detriment 
of a happy cure, obtains in some sections even to the present day. 

Resections of the maxillary bones are practiced for various dis- 
eases, the principal of which are the malignant tumors. That such 
resections are so often reported as unfavorable, has not been from 
shock, or any local injury done, but from the fact that the disease 
for which the operation was performed was in itself fatal. 

In looking, after an interval of months, and, in a few cases, of 
years, at individuals upon whose jaws the author lias personally per- 
formed resections, he has been astonished at the correction, on the 
part of nature, of deformity. The little German boy, alluded to in 
the chapter on Necrosis as having lost the left half of the inferior 
maxilla, without at the time any reproduction, looks to-day as though 
no such loss had ever occurred ; his face is exactly as it was before 
the operation, and, so far as may be judged, the ability to masticate, 
allowing for the loss of the teeth on that side, is about as good as 
ever. This, however, is an uncommon case, the result without 
doubt of the youth of the patient. 

Oilier, by his experiments upon the osteogenetic properties of the 
periosteum, has done good service to oral surgery. It is now a 
common practice in all resections to spare and save all this tissue 
possible. In the chapter on Necrosis the author has alluded to his 
own success in this direction, having replaced entirely, with the 
exception of the alveolar process and teeth, the whole of the body 
of the lower jaw through the process of enucleation. 

It is not to be forgotten, however, that the seeds of a disease, so 
to speak, may be left in a part by an attempted preservation of peri- 
osteal tissue. This fact is always, in all classes of resection, to be 
borne prominently in mind: periosteal tissue is not to be saved 
unless healthy. 

To make a complete resection of either maxilla implies, ordinarily, 
a preliminary uncovering of the affected bone. The incisions to 
such ends are necessarily various, being influenced by the condition 
of the parts beneath. They are not, however, always necessary. 
Prof. Horner, as exhibited in Plate XVII., has removed the upper 
jaw of the left side without preliminary incision ; and in two favor- 
able cases I have myself succeeded, without difficulty, in doing the 
same thing. 

In the case of tumors of magnitude and importance, these sub- 



1060 ORAL DISEASES AND SURGERY. 

integumental operatioDS are not, however, to be commended. A 
wound, or incision, made to expose such tumors, may be united by 
the first intention, leaving little or no scar, while certainly the ex- 
posure obtained through such incisions compensates by the liberty 
and rapidity of movement allowed in the subsequent steps of an 
operation. 

Subfig. 1, Plate XYIL, exhibits the mouth of the patient of the late 
Dr. Horner, immediately after the removal of the superior maxillary 
bone without external incision. Fig. 2 is a side view of the bone 
removed, and Fig. 3 is the likeness of the patient taken three years 
after the operation. The operation, as practiced by Dr. Horner, is 
thus described by his son-in-law, Prof. Smith : " Having determined 
to avoid cutting through the cheek, as commonly practiced, the pa- 
tient was seated in a chair, with his head well supported, and par- 
tially etherized. The assistant, supporting the patient's head, then 
raised the angle of the mouth on the left side,* and held it widely 
open, while the upper lip and cheek were dissected from the superior 
maxilla as far back as possible, in a line parallel with the superior 
margin of the buccinator muscle. The two incisor teeth on the left 
side being then drawn, the corresponding alveoli were cut through 
in the middle line by a narrow saw, which worked its way from the 
mouth into the left nostril ; then a pair of strong hawk-bill scissors, 
such as are used by gardeners for lopping off twigs, took out the two 
vacated alveoli at a clip. 

" A thin, flat, well-tempered knife, with a strong, round handle, 
was now struck through the roof of the mouth into the nose, at the 
junction of the palatine processes of the palate and superior maxil- 
lary bones (posterior middle palate suture), so as to cut forward and 
separate the maxillary bones from each other in the middle, when 
the narrow saw was again used to cut through the root of the nasal 
process of the maxillary bone, and strong scissors, curved on the 
flat, made to cut through the orbitar palate at its margin, the inci- 
sion being carried back to the pterygoid process of the sphenoid, 
around and below the malar bone. 

" The base of the soft palate being then detached by a short, tri- 
angular knife, curved on the flat, so as to leave the soft palate at- 
tached to the palate-bone, a few touches of the knife freed the 
remaining attachments. 

" The pterygoid process, malar bone, and the orbitar plate of the 

* The figure, by an error, is made to show the operation on the right side. 



Hate 










l/JBte' 










u 





7 :"■■'■■:' 



^m J 



N^^ 




-' 







If 



RESECTIONS OF THE MAXILLARY BONES. 1061 



upper maxillary, were not disturbed. The tumor, — which was scir- 
rhous, — besides its bony connection, was also attached to the pos- 
terior part of the cheek, and to the external pterygoid muscle. The 
gouge and scissors, however, sufficed to remove every part that 
could be detached. 

" The bleeding was profuse, especially from what was believed to 
be the posterior palatine artery, but the vessel was readily secured 
by means of a ligature and Physick's needle, and a few other liga- 
tures, with charpie, arrested the remainder of the hemorrhage." 

The ordinary operation for the removal of the superior maxillary 
bone may now be described in detail.* 

If the disease for which such an operation is to be performed is a 
tumor of moderate dimensions, say scirrhus, as in Prof. Horner's case, 
— which seldom attains to large size, — the uncovering of the part is 
to be effected by dividing the superior lip in the middle line, carrying 
the incision upward along the base of the ala of the diseased side to 
the inner canthus ; the flap thus secured, which is triangular, is dis- 
sected off as far as possible. Now remove the central teeth, and, 
with a scalpel, make an incision along the middle line of the hard 
palate as far back as the palato-maxillary articulation ; at right angles 
with this incision make a second, extending to the tuberosity of the 
maxilla, the cut to be as nearly as possible on the line of the articula- 
tion. Examining at this stage a skull, — which it is never amiss to 
have by,*)- — take up a Hey's saw, and with delicacy and accuracy cut 
across the nasal process, leaving, if possible, the orbital plate. Next, 
with the same saw, cut across the maxillo-malar articulation; this 
completes the two upper sections. The third, the intermaxillary, is 
quickty effected by introducing within the nostril one blade of the 



* An arrangement in the shape of a double tracheal canula has just been 
introduced into German surgery, and has received much encomium; this, of 
course, necessitates the preliminary operation of tracheotomy. The canula 
being put in place, the breathing of the patient is in no way interfered with 
by the hemorrhage, thus permitting the exsection to be made without that 
haste generally found so necessary. 

| In a review of the first edition of this book, " Diseases and Surgery of the 
Mouth, Jaws, and Associate Parts," fault was found by the critic with this 
suggestion. To some, such reminders may not be necessary ; the author, 
however, has always found them serviceable as immediate hints for delicate 
and accurate manipulations. "With a patient etherized, there can be no 
objection to the presence of such a model. 



1062 ORAL DISEASES AND SURGERY. 

large cutting forceps, the other being placed on the line of the articu- 
lation within the mouth, as far back as the point of union with the 
palate-bone; the incision is now made, and the separation, so far as 
cutting is concerned, is completed. Take now a pair of strong 
forceps, and, seizing the bone, twist it from its bed. 

The hemorrhage, the matter next demanding attention, varies very 
much with circumstances. It may be that twenty arteries will jet 
their blood into the face of the operator, or, on the contrary, only 
two or three may require artificial means for their control. One 
need not be either hasty or timid about this bleeding. Water, fully 
saturated with alum, simply squeezed into the cavity from a sponge, 
will oftentimes control it. If this should not answer the purpose, 
a syringe may be used, throwing the water against the vessels from 
some little distance. The casting of a ligature around a vessel is, 
however, a matter as easy as it is simple. Wash away the blood 
until the orifice of the bleeding artery can be seen, catch it with the 
tenaculum, or forceps, draw it thus a little from its sheath, and tie 
it. Repeat this with each vessel until all are secured. 

That proper form and support may be given to the integuments, 
the next step in the operation is the stuffing of the wound. To do 
this, take a number of pieces of old linen, or patent lint, fold them 
into small squares, saturate these with sweet oil, and, one by one, 
pack them into the cavity until the contour of the part corresponds 
with that of the other side. The surgeon must bear in mind how 
many of these squares he has used, that he may have the assurance 
at a future period that all have been removed. 

Rotundity and form secured, the flap is next laid carefully into 
place, and closely, but not tightly, approximated by a sufficient num- 
ber of stitches of the interrupted suture. It is generally the best 
plan to put a pin or stitch first in the lip, thus insuring correct ap- 
proximation at this most important point. 

As a dressing, simple cold water, if deemed necessary, may be 
used, keeping the parts constantly cool by its continuous renewal ; 
or, if water alone is found insufficient to control vascular excitement, 
it may be medicated with lead in the proportion of 3y to Ixvj. 
Cold water, however, will generally be found sufficient. 

Concerning the pads or squares inside, it will be found the best 
practice not to allow them to dry from the time of their first intro- 
duction. This is to be prevented by the repeated dropping among 
the pads of drops of oil from a tubed vessel. 

The stitches used in approximating the external wound are to be 



RESECTIONS OF THE MAXILLARY BONES. 1063 

removed as soon as possible : three or four days will generally allow 
of such removal. It is well to remove them gradually, taking away 
intermediate ones. 

The withdrawal of the squares is to be effected leisurely : indeed, 
the principle is to consider them as a tent, to be thrown out as the 
wound granulates and fills up below them ; pick out the top or middle 
ones, as the irritation produced by their over-retention compels you. 
Or, if it seem necessary, after the first three days have passed, they 
may all be removed, and renewed, in lessening numbers, daily. 

This completes the surgical proceedings of such a resection. 

Many cases, however, occur where the external incision here sug- 
gested might not be the best one, and, indeed, where it might not 
be sufficient to uncover the disease. Certain surgeons prefer to ex- 
pose the bone by an incision, commencing at the angle of the mouth, 
and passing obliquely in front of the Stenonian duct to the centre 
of the malar bone, throwing thus the flap upward and inward from 
below. Another mode is to use both these incisions upon the same 
subject, a necessary proceeding, in many cases, where the tumor is 
large. 

"Mr. Fergusson, who is particularly successful in oral surgery, 
in remarks after an operation for the removal of disease affecting the 
alveolus and antrum, made some important and interesting observa- 
tions, having reference generally to the exposure of such parts prior 
to the removal of the actual disease. He said that formerly, and 
even now, some surgeons were in the habit of freely dividing the 
integument of the cheek, lip, etc., trying to get at the disease from 
various points : that one method he pursued with advantage (as in 
a case of removal of malignant disease of the upper jaw) was to 
divide the upper lip in the median line, and then by carrying the 
incision on one or both sides, as the circumstances of the case re- 
quired it, into the nose, to dissect back the upper lip, ala nasi, and 
cheek, and thus expose the parts freely, avoid the deformity of scar 
on the cheek, or, to use his own words, ■ to leave as few marks of 
the surgeon's doings on the face as possible.' In a case before him 
at the time the remarks were made, — a young woman, — he was able 
to remove the disease without interfering with the lip. It affected 
the alveolar ridge of the right side, extending from the second incisor 
to the second molar, and was continued into the antrum ; but whether 
it first arose in the antrum or the alveolus, he did not know. Mr. 
Fergusson attributed the success attending this method of removal, 
in a great measure, to the instrument he used, viz., a pair of clipping 



1064 ORAL DISEASES AND SURGERY. 

forceps. He first clipped away the alveolar ridge, and then attacked 
the portion of disease situated in the neighborhood ; by this means 
freely laying open the antrum and nostril. He alluded to a case in 
which Mr. Bowman successfully removed a large tumor from the 
antrum extending into the mouth, without dividing the lips." 

Such a mode of uncovering a tumor of limited size is admirable: 
the section will be found to make a large exposure, but the scar left 
will scarcely be remarked. 

Operation for Resection of both Superior Maxillae. — It has 
never fallen to the lot of the author to resect, or to see resected, 
both maxillary bones. Several such operations are, however, on 
record ; and from them may be selected that of Heyfelder, as being 
the one most practicable and easy of accomplishment. 

The patient is to be seated in a chair, with his head supported by 
an assistant, or, better, he may lie down. An incision is made on 
each side of the face, from the external angle of the eye to the labial 
commissure ; the included parts are now reflected upward toward 
the forehead until the infra-orbital ridges are exposed. This uncovers 
the whole of both bones. The chain saw is now passed through the 
spheno-m axillary fissures, the malar bones are divided, the maxillss 
separated from the ossa nasi, and the vomer and thinner bones are 
cut with strong scissors. These steps complete the separation, when 
the bones are to be pried from the cavities with elevators or twisted 
away with the lion forceps of Liston. The result of an operation 
thus performed by the deviser himself is described as follows: " Very 
little blood was lost, torsion and compression sufficing to arrest the 
hemorrhage. Two hours afterward, the edges of the wound, from the 
angles of the eyes to the corners of the mouth, were united by twenty- 
six stitches of the interrupted suture ; cold lotions were applied : there 
was no reaction or swelling, and the patient could swallow water 
and broth. Four days subsequently, the wound had nearly healed 
by the first intention, and in six weeks the patient was exhibited to 
the Medical Society of Erlachen. At this time there was no deformity 
of the features : a fissure, thirteen lines long and three wide, was seen 
along the median line of his mouth ; the soft palate and uvula were 
in their natural place ; deglutition was free ; the nose had assumed 
its original form and direction. And the face, which, before the 
operation, was like that of a monkey, again possessed a human 
expression ; a firm and solid tissue replaced the extirpated parts." 

Resections of the Inferior Maxilla — in whole and in part. 
— Partial resections of the lower jaw have become so common as to 



RESECTIONS OF THE MAXILLARY BONES. 1065 

elicit little attention. The author has himself made such sections 
in not less than a hundred cases. The causes necessitating such 
operations are considered in other parts of this work. (See chapters 
on Tumors.) 

Subfigures 6, 7, and 8, Plate XVII., exhibit various steps in such 
resection, and are photographically true, allowing for the absence of 
the blood. 

For the removal of a class of tumors having origin back of the 
superior maxilla, Langenbeck has proposed what he terms the osteo- 
plastic resection of the jaw. This operation consists in detaching 
the jaw from its relations, except at one side, and then forcing it in 
the direction of the attached part,- — that is, turning it out of place. 
He removes the tumor, and, after controlling the hemorrhage, re- 
places the bone. 

Where, in this operation, may be the related part, is somewhat a 
matter for the preference of the operator, or otherwise is directed 
by the peculiarities of special cases. Langenbeck himself, after ex- 
posing the bone, as in the ordinary operation, passes the saw through 
the maxillo-malar articulation, along the orbital angle, and then 
without further section, if possible, turns the bone toward the mesian 
aspect: if this may not be done, he then makes section of the palatine 
raphe. As a modification of this operation, Dr. Cheever, -a Boston 
surgeon, separates the nasal and malar attachments, leaving in rela- 
tion the palatine, thus throwing the bone downward. 

In the removal of large and threatening nasal and naso-phar} T ngeal 
polypi, osteoplastic operations of the most severe character find 
commendation in the greater risk they are designed to avoid. 

A mode of getting at these tumors, when they spring from the 
spheno-occipital base, and one which, on a single occasion, was prac- 
ticed with most satisfactory results by the author, consists in splitting 
the soft palate, and by a ligature passed through the apex of either 
flap drawing the veil aside. 

Still another mode, one practiced by Oilier, applying more par- 
ticularly where tumors are situated well back in the nares, consists 
in making a U-incision over the bridge and along the sides of the 
nose, having the apex looking toward the forehead ; the flap, which 
is the nose, is now turned downward. Should space enough for the 
manipulation needed be not thus obtained, Oilier uncovers by a 
second incision the maxilloe, and saws away such portions of the 
bones as may be found necessary. 



1066 



ORAL DISEASES AND SURGERY. 



Complete section of the lower jaw is one of the most disfiguring 
and comfort-destroying operations that can be practiced on the living 
being, and is never to be performed without the existence of a well- 

FlG. 351. — ^MoUTH-StRETCHEE. APPLIED. 




recognized or proven necessity. Any section of the alveolar process 
may generally be easily accomplished without external wound, the 
lips being held out of the way by the mouth-stretcher used in the 
performance of dental operations. 



Fig. 352. 




A second form of mouth-stretcher, or lip-holder, one devised by 
Dr. Goodwillie, is shown in Fig. 352. This instrument takes up less 



RESECTIONS OF THE MAXILLARY BONES. 1067 

room, and on that account may, in many cases, have preference over 
the former. 

In cases where section of the lip may be thought desirable, as 
when the practitioner, from inexperience, may not be able to accom- 
plish the removal without such exposure, various cuts are proposed. 
These cuts may be fully understood by the studies presented. Sub- 
figure 8, Plate XYII., represents exposure of the mental portion of 
the bone. The flaps, 1, 2, are made by a single vertical incision 
through the median line of the lower lip, crossed by a second at right 
angles at the base of the jaw, extending on either side, laterally, as 
far as the bone is required to be removed. 

Subfigure 7 represents the exposure of the whole left half of the 
jaw. To accomplish this, make a first incision in the median line 
to the under border of the bone. From this carry a second under 
the jaw — although along it — to the temporo-maxillary articulation. 
Dissect now the flap upward. In the horizontal cut here made it 
will be perceived that the facial artery is divided ; this is a large 
vessel, and requires a ligature. It will be found the better practice 
to tie both ends before proceeding to the operation upon the bone. 
The coronary artery, cut in the vertical incision, will often compel a 
ligature. 

Subfigure 6 exhibits an exposure of the whole body of the bone. 
This is accomplished, as seen in the drawing, by a simple horizontal 
incision along the base of the jaw, being carried from angle to angle, 
and the flap, including the mouth entire, thrown up ; or it may be 
secured by joining the horizontal to a vertical incision made from 
the angle of the mouth ; or, as in Fig. 8, by the median, vertical, 
and horizontal incisions. These sections understood, any required 
modification will suggest itself. 

Subfigures 4, 5, 6, represent an operation practiced by Dr. J. 
Rhea Barton : 4 exhibits the tumor, which will be seen to be of 
great bulk, being described as having complete possession of the 
mouth, forcing the tongue into the pharynx, and stretching the jaws 
widely apart. It also rose up outside the superior maxillary bone, 
protruding the lips, cheek, and neck on the left side. 

Finding, by examination, that the base of the bone might be left 
with promise, Dr. Barton made the resection as exhibited by the 
lines in 5. This was accomplished by sawing horizontally from 
without inward, commencing at the middle line below the canal, 
and extending the section bilaterally. The removal of the bone, in 
this particular operation, gave no hemorrhage requiring attention. 



1068 ORAL DISEASES AND SURGERY. 

The flaps being replaced and stitched, the patient was well in a 
month. 

Complete section of the jaw, as exhibited in Fig. 8, after the prac- 
tice of Dupuytren and many successors, destroys forever the articu- 
lation of the jaws, and interferes not only with mastication, but seri- 
ously with deglutition and speech. Exposing the bone as directed, 
the section is most easily made with either the Hey, metacarpal, or 
chain saw. Before, however, shaving from the bone its inner attach- 
ments, a loop of waxed silk, or silver wire, is to be passed through 
the tip of the tongue, that thus this organ may be prevented from 
being drawn back into the pharynx by the genio-hyoid and stylo-hyoid 
muscles. 

Subfigure 7 exhibits the removal of one-half the maxilla. Ex- 
posing the bone as directed, remove one or more of the centre teeth ; 
next, from without inward, saw through the bone, or, if preferred, 
use a chain saw, carrying it around the bone by the aid of a curved 
needle. Catching now the bone in the grasp of the forceps, or using 
the fingers, as preferred, detach the inner soft parts, twisting the 
bone outward and downward. Arriving, in the dissection, at the 
coronoid process, the temporal tendon is to be detached by a chisel- 
shaped knife, care being taken not to wound the maxillary artery or 
internal carotid. This process freed, the condyle can be twisted 
from its ligaments, or, better still, twisted and at the same time cut 
away. This operation, apparently so formidable, the author has 
succeeded in doing without external incision. With the section of 
the soft parts, as represented in the figure, it is not nearly so difficult 
as might be supposed. A diseased bone is seldom so difficult to 
disarticulate as a sound one. 

Prof. Smith, in his System of Surgery, gives the credit to Dr. Geo. 
McClellan of having been the first to attempt more than a limited 
section of this bone, — this surgeon, in 1823, having removed all the 
parts anterior to the angles. In this, however, he was preceded by 
Deadrick, of Tennessee, who, in 1812, made a resection which ex- 
tended from the symphysis to the angle. Prof. Mott, of New York, 
is also referred to as having made an operation similar to Deadrick's, 
in 1821. Dr. Ackley, of Cleveland, Ohio, is reported as having, in 
1850, removed the bone entire. In Europe, priority of the operation 
performed first by Deadrick is awarded to Dupuytren. Mott, ac- 
cording to Prof. Smith, disarticulated the bone, — Deadrick and Du- 
puytren did not. Prof. Mott thought it necessary to ligate the 
primitive carotid artery a few days before making his resection, a 



RESECTIONS OF THE MAXILLARY BONES. 1069 

step long since proved to be entirely uncalled for, complicating and 
increasing the dangers of the operation. 

The performance of Dr. Deadrick, deservedly famous for its pri- 
ority, was done on the person of a lad fourteen years of age. The 
operation was for the removal of a cartilaginous tumor on the left side 
of the jaw, which filled up nearly the whole of the mouth, causing the 
greatest difficulty in swallowing, and, at times, even in breathing. To 
accomplish his resection, Dr. Deadrick commenced an incision under 
the zygomatic process, and carried it across the tumor, downward 
and forward, to nearly an inch beyond the middle of the chin. From 
the centre of this first incision, and consequently at right angles with 
it, an incision was extended a short distance upon the neck; the 
flaps thus secured were dissected from the diseased mass, and the 
bone next sawed off at the angle and symphysis. The flaps were 
laid back in the usual way, the boy making a speedy recovery. 

Nerve Section. — A most interesting department of resective sur- 
gery — for it may be thus termed — is found in the operations required 
to expose nerves involved in neuralgic lesions. It is certainly no 
longer a question that sections of nerve-cords may be made without 
special danger or risk, — the greater question being always the estab- 
lishment of a correct diagnosis. In the chapter on Neuralgia occa- 
sion was taken to remark that such operations w r ere far from being 
satisfactory; but that remark is here to be modified by pronouncing 
the fault, in many of the cases, to be rather with the surgeon than 
with his case. Section of a nerve is only justified where on the peri- 
pheral side there exists a lesion which may not otherwise be cured ; 
and of such cases there are, without doubt, many. 

Section of Inferior Maxillary Nerve. — While it cannot be 
denied that many of the reported cases of section of the inferior 
maxillary nerve have been made without necessity, yet it is certainly 
an operation to be practiced and commended. 

Reference to Fig. 353 will show that the nerve, which is a cord of 
some size, passes within the substance of the jaw midway to the thick- 
ness, and on a line which would be well enough marked by taking 
the centre between the base of the bone and the cutting edges of the 
teeth. Approaching the ramus, it ascends obliquely upward and back- 
ward, escaping operative proceeding at the posterior dental foramen. 

To expose this nerve, if within the ramus, begin au incision at 
the sigmoid notch, and carry it downward through the integu- 
ments, carefully avoiding the wounding of any overlying part of the 



1070 



ORAL DISEASES AND SURGERY. 



parotid gland; the gland discovered, push it carefully backward, 
and complete the incision down to the bone, scraping aside, rather 
than removing, the periosteum. Still another mode, and the one 



Fig. 353. 




most commonly practiced, is an incision made as exhibited in Fig. 
354, inclining, however, the base of the flap more forward than is 
shown in the diagram. As the next step, after the exposure is made, 
take a small trephine, and cut out two sections, or rather cut, with 
the trephine, sufficiently deep to reach, or very nearly reach, the 
nerve-canal. Take now the chisel, and with gentle cuts remove the 
intervening portion of bone. If the operation be carefully performed, 
the nerve can be uncovered without being wounded. Reaching 
the vessels, isolate the nerve from the artery and vein by lifting it 
upon the tenaculum. It is now to be divided, removing as much as 
is thought desirable, never less than half an inch, and if more, cer- 
tainly the better. 






BESECTIONS OF THE MAXILLARY BONES. 1071 




If the operation is to be performed within the body proper of the 
bone, the uncovering is even more simple : use the straight or curved 
line, cutting midway upon the bone, separate the lips of the wound 
by delicate retractors, securing 

thus a free exposure (with the Fig. 354 - 

periosteum scraped away, as be- 
fore suggested), trephine, and 
remove the section. 

The facial artery, it is not 
to be forgotten, passes in front 
of the masseter muscle; if this 
is necessarily cut, the operator 
must stop and throw a ligature 
about it: it is better to tie both 
ends. Cuts into the muscular 
substance are to be avoided as 
much as possible; such incisions 
add to the trouble of an opera- 
tion by the free hemorrhage 
provoked. 

A section of the nerve-cord secured, the surgeon carefully lays 
back the flaps and watches the result. It has been thought well by 
some to give large doses of an opiate immediately after such opera- 
tions ; but when this is required, unless opiates have been made a 
necessity from abuse of the means, I think the operation will be 
found to prove a mistake, as in such successful cases as have occurred 
in my own experience, the relief from suffering experienced has acted 
as the profoundest of opiates, — the patients sleeping for the first few 
days almost continually. 

Where, on the contrary, a patient has long habituated himself to 
the use of opiates, a continuation will be found as much a necessity 
as is stimulation in delirium tremens : here, indeed, the neuralgia 
corresponds with Dr. Anstie's view that it is a condition of depres- 
sion. 

To cure a patient of the necessity for the stimulation of opium is 
not unfrequently found a more difficult task than was the true treat- 
ment of the original cause of the pain. 

Superior Maxillary Nerve. — Section of the branches of the 
superior maxillary nerve is practiced with a difficulty corresponding 
to the requirements of the various cases. The case of a Mrs. B., 



1072 ORAL DISEASES AND SURGERY. 

recorded on page TIT, affords an example of an easy manner of 
cutting those branchlets which cross the antrum from the intra- 
orbital foramen. Branches known as the infra-orbital — that is, those 
which, bush-like, expand from the infra-orbital foramen — are easy of 
a common division through a trap-door-like flap made upon the cheek 
over the position of that foramen. 

Cases, however, occur, where pain is so diffused over the track of 
the second division of the fifth nerve, and where the suffering of the 
patient is so intolerable, as absolutely to force the surgeon into oper- 
ation even in the absence of a perfectly reliable diagnosis, and when 
it is felt that no section outside of the main branch may promise 
auy good. In these instances, the results too frequently prove the 
worse than empiricism of the practice ; too often does continuous 
pain, transferred to some other part, show that the lesion is still 
back of the seat of operation. The author does not, however, con- 
demn these operations: desperate evils call for desperate remedies. 
He would only enjoin that it be well understood that a desperate 
remedy must not be uselessly or unnecessarily employed, and that 
no man should undertake the resection of the superior maxillary 
nerve until he is assured that he has mastered all that can be known 
of the case. The chapters in this book on Neuralgia and Odontalgia 
will be found full of hints, experiences, and suggestions in this direc- 
tion, and may be referred to with benefit. 

The exposure of the second branch of the fifth nerve was first 
practiced in this country by Dr. Carnochan, of New York, and the 
plan originally adopted by this surgeon for the exposure is the same, 
with unimportant modifications, as that still practiced. 

Commencing this operation, *a Y-shaped or simple curvilinear 
flap exposes the anterior wall of the antrum. A trephine, as large 
as may be used, is now made to remove this wall. The posterior 
wall thus exposed, a second trephine, necessarily somewhat smaller 
than the first, removes a section of this; the spheno-maxillary fossa 
thus exposed, the nerve is found and isolated from its surroundings 
and as much of it removed as may conveniently be effected. If, in 
the opening made through the antrum, space enough has not been 
secured by the trephine, the operator will find himself compelled to 
remove, by means of chisels and cutting pliers, the lower boundary 
of the infra-orbital canal; this will be found to enlarge the working 
space considerably. 

In seeking in the fossa for the nerve, too much delicacy cannot be 
exercised, as above all things is it desirable to have, if possible, a 



RESECTIONS OF THE MAXILLARY BONES. 1073 

healing of the parts without degeneration or destruction of the 
tissues. 

A mode of exposing the antral wall, affording greater convenience 
in the succeeding steps of the operation, consists in dividing the lip 
and cheek by an incision leading directly from the labial commissure 
to the malar bone: two flaps are thus created, one being directed 
inward, the other outward. 

An operation devised by Langenbeck for section of this nerve, 
being, however, one that is scarcely likely to meet with much favor, 
consists in the use of a stout tenotome, which is to be thrust, with 
its point directed downward and backward, immediately beneath the 
external palpebral ligament, being kept in close contact with the 
outer wall of the orbit until it reaches the spheno-maxillary fissure, 
this being recognized in the cessation of resistance. The edge of the 
knife is now turned so as to shave the surface of the bone, the 
nerve being cut by a sawing motion as it enters the orbital canal. 
A cut opening the canal is now to be made through the floor of the 
orbit, and with a hook the nerve is to be caught and pulled from its 
bed. 

Pancoast's operation for exposure of the second and third branches 
of the trifacial is performed as follows : First, as exhibited in Fig. 
354, a trap-like flap is made across the ramus of the lower jaw. 
This being raised and reflected, the masseter muscle is shaved from 
its attachment, and the coronoid process exposed ; this process is 
next sawed off at its root, and, having detached from it the temporal 
muscle, is removed ; the muscles being thrust upward out of the 
way. This series of manipulations exposes the spheno-maxillary 
fissure, across which, but overlaid with some fatty tissue, passes 
the internal maxillary artery, which a succeeding step picks out and 
ligates. The next use of the knife is found in detaching from the 
great ala of the sphenoid bone the external head of the pterygoid 
muscle ; this accomplished, any sc>ft parts found in the way are to 
be pushed aside with the finger, after which attention is to be given 
to staunching the hemorrhage and oozing. 

The parts thus exposed and dried, the nerves of the zygomatic 
fossa are plainly visible, and may be exsected by using a pair of 
curved scissors. 

Exposure of the second branch after this manner of operation is 
a complicated matter. From the point gained, an incision is to be 
carried upwards and inwards to the spheno-maxillary fossa as far as 
the external rectus muscle. By means of a hook carrying a well- 



1074 ORAL DISEASES AND SURGERY. 

waxed thread, the nerve is now to be encircled and so controlled as 
to allow of section being made with the knife; all that portion being 
removed which lies between the foramen behind and the bones in 
front, — about the third of an inch. 

Inversion and Eversion of the Lip. — It sometimes happens 
that, from accident or congenital defect, the lip — generally the lower — 
is inverted or everted. When turned inward, the part is shortened, 
and not unfrequently permits the escape of the oral fluids. Inver- 
sion, while generally the result of some cancroid affection which 
has produced considerable cicatricial tissue, is yet occasionally ob- 
served associated with some perversion of the fraenum, this fold being 
unduly short, or running too near the free edge of the lip. A case of 
inversion, the worst the author has ever met, resulted from a gun-shot 
wound, involving both lip and jaw. In this case that surface which 
was the free edge had become involved in the reparative material 
near the base of the alveolar process, and had thus become tightly 
bound to these parts; the teeth, and face of the gums, being exposed. 
To prevent the dribblings from his mouth passing to the neck and 
breast, the patient had constructed for himself a species of tin cup, 
which he constantly wore bound to his chin, and which was con- 
cealed from observation by a large neckerchief. 

Eversion, the more common condition, depends, like inversion, on 
a variety of causes. A burn received about the chin, contracting 
the part, has frequently produced it. Hypertrophy of the mucous 
membrane is an occasional cause ; preternatural elongation of the 
fraenum permits such falling outward. Any loss of substance exter- 
nally, contracting the parts, necessarily tends to eversion. 

Treatment of inversion or eversion varies, of course, with the 
various causes. In the inversion of the lip where such cause lies in 
the existence of cicatricial tissue, it will be found easier to devise 
than to secure the means of cure. If the lip has length, operation 
may be attempted by an elliptical portion taken from the outer surface, 
the parts being brought together and an immediate union secured 
through the use of the hare-lip pin or common interrupted suture ; 
if, on the contrary, the lip has been shortened in its bulk, as is fre- 
quently the case where the ulcer has been deep, we must depend 
for relief on a plastic operation : such an operation consists in cut- 
ting away the cicatrix and transplanting a pedicled flap, to be made 
as directed in the chapter on Autoplasty. 

A shortened or improperly attached fraenum is, generally, most 



RESECTIONS OF THE MAXILLARY BONES. 1075 

easy of correction, — a section, more or less extensive, assisted by a 
frequent turning outward of the parts by the patient, quickly result- 
ing in the cure. 

Inversion from gun-shot injuries classifies itself with contraction 
from ulceration ; each case is a study in itself, and will be found to 
have its own peculiar demands. Many of these conditions have no 
cure, the patient being doomed to drag through an undesirable ex- 
istence. Others will be found very easy of remedy, some attached 
point requiring, perhaps, alone to be freed. An intermediate class, 
and this is by far the most common, demands a combination of ope- 
rations, — such requirements suggesting themselves to the ingenious 
surgeon. 

E versions are treated on the same general principles. An ellipsis 
from the mucous face of the lip is the most common mode of cure 
resorted to. A second mode is a double Y-shaped incision, the centre 
of the cut being the centre of the lip ; the space within, being wider 
than that without, naturally draws the parts inward and downward. 
In preternatural elongation of the frsenum I have secured satisfac- 
tory results by cutting out a limited portion of the bridle and pro- 
ducing an eschar by the use of nitrate of silver. Or, if the operator 
prefer, he may stitch the parts together after the abbreviation, se- 
curing the continuance of the approximation by the use of a turn or 
two of a bandage. 



INDEX. 



Abbott's pluggers 341 

Abrasion of cutting face of teeth 506 

treatment of 506 

Abscess associated with wisdom 

teeth 174 

dental 34 

of antrum 665 

of tongue 783 

of tonsil gland 528 

Absorption of alveoli 382 

of gums 382 

Accidents in root filling 388 

in tooth extraction 423 

Acid secretions 257 

Acids in treatment of dental 

caries 255 

Acne 139 

Action of ether on nerve centres. 437 

Acupressure in hemorrhage 599 

Acupuncture in trismus 199 

Acute glossitis 778 

periodontitis 149 

synovitis 183 

Adenoid tumors 936 

Adenoma 815 

Adhesion of the gums 547 

Adhesive gold fillings 307 

gold foil 307 

Administration of ether 433 

Adventitious tongue-tie 802 

Adynamic inflammation from 

dental irritation 116 

Age, relation of, to use of chloro- 
form 499 

Agents in contact with the teeth 254 

Agnew, Prof. D. H., on hare-lip 954 

on ranula 755 

Agnew's suture for hare-lip 958 

Allport's operation on dental 

pulp 393 

Alteratives in tetanus 190 

Alum in hemorrhage 115 

Aluminium for obturators 1051 

Alveolar abscess 170 

necrosis 572 

process 31, 100 

round-celled sarcoma 880 

Alveoli 104 



Amalgam 284 

Amputation of tonsil glands 523 

instruments used in 523 

of uvula 528 

Anaesthesia, general 431 

local 427 

by chloroform 441 

by ether 432 

Analysis of eggs 238 

of Indian corn 247 

-of milk 237 

of mutton fat 238 

of oats 243 

of potatoes 242 

of saliva 277, 495 

of starch 238 

of sugar . 238 

of teeth 233, 234 

of wheat 238, 245 

Anatomy of face 29 

of soft palate 66, 1015 

of superior maxilla 33 

Anchylosis of jaw 182 

Angina aphthosa 119 

chronic 121, 

treatment of 122, 123 

simplex 119 

diet in 120 

treatment of 120 

Angionoma 815, 937 

Annealing gold foil 327 

Anomalies in abscess 172 

in dentition 141 

in situation of calculi 497, 501 

Anterior palatine canal 37 

pillar of fauces 67 

Antrum of Highmore 31 

diseases of 658 

Aphthse 674 

Appearance of dead teeth 591 

Appliances used in orthodontia. 480 

Aqueduct of Fallopius 62 

Arbuthnot, on mortality from 

dentition Ill 

Arrangement of gold in filling 

teeth 322 

Arsenical paste as a cause of ulitis 541 

Arterial tumors 938 

(ion) 



1078 



INDEX. 



Arteries, anastomosis of. 62 

coronary 61 

facial 60 

lateralis nasi 37 

lingual 71 

posterior palatine 37 

ranine 71 

Arthritis 183 

Articulation, of a denture 477 

temporo-maxillary 74 

Artificial dentures 456 

muscles 991 

Ashhurst on structure of the epi- 

theliomata 921 

Aspects of dental caries 281 

Associative lesions of first denti- 
tion Ill 

Atheroma 815 

Atkinson's pluggers 337 

Atlee's suture 958 

Atomizers 429 

foot instruments 430 

hand instruments 429 

Atresia oris 973 

Dieffenbach's operation for.. 973 

Mutter's operation for 975 

Automatic pluggers 348 

Autopsies by Eokitansky in teta- 
nus 189 

Baby's sore-mouth 680 

Bad ether 428 

Bamberger's views of the nature 

of aphthae 679 

Barnum's rubber dam 312 

Bartholin's duct 74 

Barton's bandage 628 

operation for maxillary tu- 
mor... 1067 

Batley's solution in cancer 930 

Bayberry powder in hemorrhage 11 5 

Bean's interdental splint 632 

Beeswax as an impression mate- 
rial 469 

Belladonna, in tetanus c 191 

in tonsillitis 517 

Bichat's tripod 127 

Bicuspid teeth 96 

proximal cavities in 345 

Bilateral luxation of jaw 637 

Billroth on caries of bone 554 

on classification of tumors... 875 

on necrosis 580 

on the cystomata 898 

on tumors 805 

Black's engine 290 

Blisters in periodontitis 153 

Blood effusions 811 

Blue line in saturnine affections 550 

Bone, ethmoid 46 



Bone, hyoid 55 

inferior maxillary 33 

inferior turbinated 45 

lachrymal , 54 

malar 53 

nasal 52 

palate 41 

sphenoid 48 

superior maxillary 33 

Bonwille's electro-magnetic mal- 
let 348 

engine 290 

Breaks in the hard palate 577 

Bridgman's electro-chemical ex- 
periments 261 

Broach, use of. 384 

Bromide of potash in ulitis 114 

Buckingham's obturators 1040 

Bulla? 137 

Bur files 352 

Burnishers 339, 352 

Burns, plastic operations for re- 
lief of. 992 

Butler's pluggers 339 

Calcification of dental pulp.... 366 

Calculi in salivary ducts 497 

Camper on mortality of infants.. Ill 

Canal, Fallopian 88 

infraorbital 81 

interpalatine 43 

lachrymal 31, 35 

pterygopalatine 42 

vidian 52 

Canal pluggers 387 

Canals, Haversian 99 

Cancer of gums 919 

of Stenonian duct 920 

of tongue 769 

Cancrum oris 677 

Canine teeth 95 

Caps for exposed dental pulps... 153 

in dental inflammation 153 

Capsular ligament of lower jaw- 75 
Capsule of encephaloid cancer... 915 
Carbonate of magnesia in phos- 
phor-poisoning 586 

Carcinoma of jaw 914 

of lingual fossa 708 

of submaxillary region 708 

Caries as cause of death of teeth 571 

Caries of maxilla? 552 

affinity with cellular struc- 
ture 556 

illustrative cases of 563 

scrofulous associations 552 

treatment of 563 

by acids 561 

Caries of the teeth 214 

cachexia in 215 



INDEX. 



1079 



Caries of the teeth, causes of. 214 

constitutional relations 253 

differs from caries in bone.. 274 

inflammatory process of. 274 

principles of treatment 276 

Carious denture 297 

Carotid artery 66 

Catalan's inclined plane 489 

Catarrh of Schneiderian mem- 
brane 670 

Cathartics in neuralgia 738 

Causes of dental abscess 175 

of gum diseases 532 

of odontalgia 361 

of sensitive dentine 364 

Caustic potash in treatment of 

caries of bone 562 

Cauterizing sensitive dentine 363 

Cavities in teeth, rules in ex- 
cavating 305 

Cementum 98 

Chalky teeth 279 

Changes in rami of lower jaw... 489 

Character of epithelioma 926 

Cheeks, composition of 58 

Cheever, osteoplastic resection 

of jaw 1065 

Cheiloplasty 980 

operation by M. Blasius 984 

bv Chopart 982 

by Dieffenbach 984 

by Dupuytren 983 

by HornT 982 

by Liston 985 

by Mr. Morgan 984 

by Mutter 985 

bv Eoonhuysen 982 

by P. Koux 984 

byT. M. Roux 984 

byM.Serres 983 

Chimney-sweep's cancer 919 

Chisels used in dentistry 291 

Chloride of zinc in sensitive den- 
tine 363 

Chloroform 441 

action of 442 

at different temperatures 443 

in association with age 448 

with hysteria 449 

with strength and de- 
bility 449 

in cerebral disease 452 

in disease of the heart 450 

in diseases of the lungs 450 

in insanity 453 

in pregnancy 450 

Chloroma 814 

Chromic acid in treatment of 

warts of the face 949 

Chronic periodontitis 149 



Cicatrix in hare-lip 961 

Ciliary ganglion 87 

Clasp teeth 467 

Cleft lip 967 

palate 1009 

operation by Fergusson 1021 

by Garretson 1021 

by Koux 1020 

by Warren 1020 

Clinical distinction of tumors... 806 

histories of neevi 945 

peculiarities of carious bone 557 

Cloquet's ganglion 87, 89 

Cobweb in hemorrhage 115 

Cold in anaesthesia 429 

Color in calculi 502 

Columnar epithelium 72 

Comminuted fractures 633 

Complete luxation of jaw 637 

Complexion in necrosis 588 

Complicated dental cavities. ..298, 303 

fractures 633 

hare-lip 964 

wounds 609 

Compression in hemorrhage 599 

Condensation of fillings 354 

Condyloid processes 40 

condition of, in luxa- 
tion 638 

Congenital luxation of jaw 640 

tongue-tie 802 

union of gums 547 

Conjoined loss of nose and lip... 989 
Constitutional diseases associated 

with antral disease 664 

Contour fillings 304, 347, 355 

Contracted dental arch 142 

Contracted oral orifice 973 

treatment of, by Dieffen- 
bach 973 

treatment of, by Mutter 975 

modification of, by Gar- 
retson 976 

Convulsion from irritation of 

teething 92 

Corks, use of, in jaw luxation... 641 

Coronary arteries 61 

Corpuscles, Purkinjean 99 

salivary 276 

Cow-horn forceps 406 

Crapulous diarrhoea 127 

Creasote as a cause of ulitis 540 

in dental caries 280 

in treatment of caries 565 

Cribriform plate of ethmoid 

bone 46 

Crista galli of ethmoid bone 46 

Crusta petrosa 98 

Cuspidati teeth 95 

Cutting forceps 415 



1080 



WD EX. 



Cutting teeth, irritation from... 112 

Cystic tumor of cheek 983 

Cystoma of parotid region 931 

Cysts, general diagnosis of 816 

of antrum 870 

from dental abscess 817 

of salivary duets and glands 696 

of tongue 776 

of tonsil glands 526 

Cytoblasts 105 

Data for diagnosis of dental 

tumors 867 

Dead teeth, how exfoliated 571 

Death of teeth from structural 

consolidation 571 

Deciduous teeth 93 

tooth -pulp 143 

Deep-seated ranula 700 

Dental abscess ; 170 

anomalies 141 

caries 214 

from accidental causes. 269 

from acid secretions 257 

from agents in contact 

with the teeth 254 

from constitutional re- 
lations 253 

from dyspepsia.-. 254 

from electro-chemical 

relations 261 

from mechanical de- 
structives 269 

from medicines and ar- 
ticles of food 267 

from mucous deposits... 255 

from parasites 259 

from rickets 215 

from scrofulosis 215 

from shape of teeth 251 

from syphilis 215 

chairs 325 

fever 124 

fistula 170 

irritation, epilepsy from .... 133 
influence of, on skin dis- 
eases 186 

necrosi s 568, 569 

neuralgia 736 

periostitis 149 

pulp 102 

syringe 305 

Dentifrices 270 

Dentio'erous tumors 846 

Dentine 97, 103, 105 

consolidation of 275 

Dentinoma 815 

Dentition as a cause of ostitis.... 568 

first, associative lesions of... Ill 

diarrhoea from 126 



Denudation of enamel 505 

cause of 505 

Dermatitis 135 

Desirabode's obturators 1047 

Destroying dental pulp 371 

results of 570 

Devitalized dentine 390 

Dewar's dressing 959 

Dewees's views on the aphtha?... 680 

views on tongue-tie 801 

Diagnosis of carious dentures 297 

of epithelioma 922 

of luxations 638 

of maxillary caries 554 

of maxillary tumors 808 

of ranula 696 

Diarrhoea from milk of nurse.... 127 

of dentition..... 126 

Dieffenbaclrs button obturator.. 1031 

Digitalis in tetanus 191 

Diminution of pulp chamber 877 

Diseased teeth as cause of antral 

trouble 659 

Dislocation of inferior maxilla.. 426 

Dissection of soft palate 1016 

Domestic treatment of holes in 

the palate 1032 

Drilling engines 290 

Drills 288 

Dropsy of the antrum 663 

Dryness in filling teeth 308 

Dubs's screw-forceps 417 

Duct of Bartholin 74 

Eivinian 74 

of Steno 73 

of Wharton 74 

Ductus ad nasum 31, 35, 54 

Duplay's nasal speculum 657 

Duration of shock 603 

Ebukntfication of dentine 280 

Eccentric fibromata 877 

Ecthyma 139 

Eczema 139 

Effects of tartar 495 

Effusions in synovitis 183 

Electro-chemical cause of dental 

caries 261 

experiments with amalgam. 286 
explanation of dental denu- 
dation 505 

Electro-galvanism in tooth ex- 
traction 428 

Electro-magnetic mallet 348 

Elephantiasis 139 

Ellipse in hare-lip 957 

Elsberg's mouth-gag 1028 

Enamel 97, 105 

calcification of 103, 106 

formation of. > 102, 105 



INDEX. 



1081 



Enamel nodules 835 

pulp 102, 105 

Encephaloma 815, 915 

Enchondrom a 815 

Enlargement of tonsil glands 519 

Enteritis 128 

Epidemics, furuncular 671 

Epiglottis 71 

Epilepsv from irritation of teeth- 
ing 92 

Epithelioma 918 

forms of 918 

from irritation of jagged 

teeth 919 

llustrations of 918 

of eyebrow 992 

treatment of, by plastic 

operation 992 

of tongue 773 

pearl formations 926 

treatment of, by caustics 927 

by excision 927 

by injection 927 

Epulides... 819 

erectile 822 

fungoid growths 819 

illustrative cases 827 

non-explaining 825 

Erectile tumors 937 

Erigeron Canadensis...., 115, 425 

Eruption of teeth, convulsions 

in 133 

Eruptions on skin from dental 

irritation 135 

erythema 135, 138 

exanthemata 138 

Erysipelas 133, 138 

as a complication in epithe- 
lioma , 930 

Esmarch's operation in jaw an- 
chylosis 209 

Ethmoid bone 46 

Example in tumor diagnosis .... 809 
of anomalies in dental evolu- 
tion ..159-169 

Exanthemata 138 

in antral diseases 672 

Exanthematous necrosis 508 

Excavators 287, 301 

Excising forceps 189 

Excision of tonsil glands 523 

Exfoliation of dead teeth 571 

Exostosis 833 

Experiments of French Academy 

with ether 437 

Exposure of dental cavities 294 

of dental pulp 365 

in milk teeth 143 

of nares 1009 

Expressions of encephaloma.,915, 916 



Extension fingers 311 

Extirpation of superior maxilla. 1061 

of tonsil glands 525 

Extraction ofteeth 395 

indications for 395 

instruments used for 397, 413 

of deformed teeth 417 

Exuberant granulations in caries 552 

Eye teeth 95 



Face, anatomy of.... 

Facial arteries 

branches of. 
nerves 



29 
60 
61 

62 



paralysis 739 

veins 63 

Fallopian aqueduct 62, 88 

Fang of tooth 91, 103 

Fatty tumors of cheek 934 

Fauces, inflammation of 119 

isthmus of... 67 

pillars of 67 

Fergusson on exposure of max- 
illa 1063 

Fever, irritative 113, 124 

Fibrinous blood 985 

Fibroma 815 

Fibrous tumors 877 

Fifth pair of nerves 77 

excitor to portio dura 92 

to respiratory nerves ... 92 

functions of 90 

irritation of, in teething 92 

File, the, as a prophylactic agent 356 

Files 85, 118, 293, 352, 459 

Filling teeth 281, 346, 382 

over exposed pulps 389 

pulp chambers and canals... 384 

Finishing fillings 351 

First dentition, associate lesions 

of. Ill 

Fissure of hard palate 1009 

congenital 1011 

pressurein treatment of 1013 

uranoplasty in 1028 

of soft palate 1014 

of Sylvius 51 

of tongue 761 

Fistulse, of tongue 767 

salivary 507 

Fixed alkalies in tetanus 191 

Flagg's tongue-holder 309 

Floor of mouth 40 

Fluids of oral cavity 275 

Fly-blisters in periostitis 153 

Follicular inflammation 676 

Foramen, anterior palatine 89 

inferior dental 40 

infraorbital 32 



1082 



INDEX. 



Foramen lacerum 50, 51 

lacerura basis cranii 88 

mental 31, 91 

ovale 50, 83 

rotunclum 50, 81 

spheno-palatine 42, 89 

spinosum 50 

stylo-mastoid 63 

vesalii. 50 

Forbes's gouge chisels 293 

rubber-dam appliance 320 

Forceps for extracting teeth 399 

cow-horn 407 

Dubs's 417 

Hullihen's 417 

Hutchinson's 409 

Jones's fulcrum 412 

Perrine's fulcrum 413 

Physick's 410 

Stellwagen's 415, 416 

Stromeyer's 642 

Foreign bodies in nares 655 

particles in wounds 598 

Forget on dental anomalies 155 

Forms of gold used in filling 

teeth 322 

of hare-lip 966 

of maxillary displacements.. 637 

Formula for chloroform 441 

for sulphuric ether 422 

Fossa, canine 31 

incisor 32 

lingualis 71 

myrtiform 36 

spheno- maxillary 81 

Fractured tooth roots 414 

Fractures of maxillse 623 

Frasnum linguae 28 

Frail anterior teeth 283 

Freckles 139 

Frontal nerve 80 

Full dentures 475 

Functional tumors 814 

Fungi 259 

in dental caries 280 

in salivary calculi , 502 

Furuncular epidemics 671 

Gags for holding the mouth open 1029 

Elsberg's 1028 

Good Willie's 1029 

Kolbe's 207 

Whitehead's 1029 

Wood's 1029 

Ganglion, ciliary ;. 86 

Cloquet's 89 

Gasserian 79, 83-86 

intumescentia gangliformis 62, 68 

lenticular 87 

Meckel's 52, 86, 87 



Ganglion, ophthalmic 86 

otic 89 

semilunar 79 

spheno-palatine 86 

submaxillary 89 

Gangren'se oris 678 

Garangeot's obturator 1055 

Geist, on local origin of phos- 
phor-necrosis 585 

Genial tubercles 40 

Genioplasty 980 

Gibbs, Sir Duncan, on uses of 

uvula 592 

Glacial acetic acid in epithe- 
lioma 927 

Glands, salivary 72 

parotid 72 

sublingual 40, 74 

submaxillary ..40, 73 

Glandular tumors 936 

Glossitis , 778 

Glosso-epiglottic ligaments 71-72 

Glycerole of thymol 280 

Gold, effects of, on the teeth 275 

prepared for use in teeth.... 322 

Good on the aphthae 684 

Granulations in wounds 961 

Granules in dental pulp 374 

Green's pneumatic engine 353 

Groove, posterior dental 36 

primitive dental 101, 104 

Growth of maxillse 142 

Guillois' cement 283 

Gum-boil 170 

Gummata syphilitica of tongue. 761 

Gums, congenital union of 547 

diseases of 532 

how to lance 115 

Gunshot injuries of jaws and face 634 

Gustatory nerve 85 

Gutta-percha as a material for 

filling teeth 286 

as a material for taking im- 
pressions 472 

Hematoma 815 

Hainsby's compressor 959 

use of, in cleft palate 1011 

in hare-lip 960 

Half-arches of fauces 67, 69 

Hamamelis Virginicus 153 

Hand- and foot-lathes 190, 191 

Handles of plugging instruments 307 

Hare-lip, and operations for 952 

views on, of Agnew, Prof... 956 

Bransbv Cooper 953 

Colle, Prof.. 954 

Dupuytren 953 

Fergusson, Sir Wm 953 

Houston, Dr 953 



INDEX. 



1083 



Hare-lip, views on, of Listen, Mr. 952 

Pancoast, Prof 954 

Skey, Mr 953 

Smith, Prof. H. H 955 

Hatchet excavators 288 

Haversian canals 99 

Healing wounds 607, 961 

Healthy bone adjoining caries... 561 

Hemorrhage, after lancing gums 115 

after tooth extraction 428 

alum-water in 115 

bayberry powder in 115 

Erigeron Canadense in. 115 

' Monsel's solution in 116 

nitrate of silver in 116 

opium and lead in 115 

in operating for caries 561 

in operating for tongue-tie... 803 
Guersent's recommen- 
dation 803 

Petit's instrument to 

control 803 

in operating for wounds of 

face 599 

Hereditarj' dental caries 214 

Herpes 139 

Heterogeneous dental evolution 155 

Heterologous tumors 807 

Hill's stopping, for carious teeth 286 

as a pulp cap 393 

Histoid mixed tumors 904 

Histology of epithelial cancer... 920 

of tumors 815 

Hodson on uses of rubber-dam... 313 

Hoe excavators 287 

Holes in the palate 1026 

hard palate 1027 

soft palate 1026 

Homologous tumors 812 

Horn and Thornwaite's means of 

local anaesthesia 427 

Horner's operation for salivary 

fistula 509 

Horn-like tumors 951 

Hot-air syringe 321 

Hot and moist applications in 

neuralgia 733 

Hullihen, case of plastic sur- 
gery 994 

Hullihen's screw forceps 417 

Hulme on pulp calcification 376 

Hydatid cysts 817 

Hydrastis Canadensis in epithe- 
lial cancer 928 

Hydrops antri 871 

Hygroma 700, 815 

Hyoid bone 54 

Hyper amiia 136 

Hyperostosis 883, 839 

Hypertrophic tumors 814 



Hypertrophy of gums 543 

of tonsil glands 519 

Hysteria and anaesthesia 448 

Ichthyosis 138 

Idiopathic tetanus 187 

Idiosyncrasies, use of ether in... 439 
Illustrations of dental anoma- 
lies 157-169 

of epulides 827 

of exostoses 842 

of irregular dentures 480 

of obturators 1037 

of the odontomata 854-859 

of ranulse 699 

of staphyloraphy 1014 

of trismus 198 

of wounds of the face 609 

Imperfect dentures 251 

Impetigo + 139 

Impressions for dentures 467 

gutta-percha for 472 

plaster for 471 

trays for 468 

wax for 469 

for obturators 1033 

Incisor teeth 93 

India-rubber as a substitute for 

muscle 971 

Indications in treatment of 

wounds of mouth 598 

of dental caries 274 

of jaw fractures 627 

Infantile trismus 193 

Inferior dental artery 37, 40 

dental nerve 39, 40, 79, 1070 

maxilla, changes of 489 

fractures of 623 

maxillary bone, anatomy 

of 38 

turbinated bone 45 

Inflammation of dental pulp 365 

of fauces 119 

of jaw 567 

of periodonteum 149 

of the skin 136 

of tonsil glands 516 

Inflammatory tumors 812 

Infra-orbital canal 81 

foramen 31, 86 

Ingrassias, processes of 51 

Injury to teeth from zinc 280 

Insanity and chloroform 450 

Interariicular anchylosis of jaw 182 

Inderdental splints 629 

Bean's 682 

Gunning's 631 

Interglobular spaces in teeth 99 

Intermaxillary projections in 

hare-lip 965 



1084 



INDEX. 



Introducing fillings into teeth... 807 

Inversion of lip 1074 

Iodide of potassium in syphilis. 766 

Iodine in treatment of caries.... 564 

Iron in epithelioma 928 

and quinine in erysipelas ... 930 

Irregularities of the teeth 272, 478 

of system at large 570 

Irritation of dental pulp 365 

Irritative fever 124 

Isthmus of fauces 67 

Jack's chisels 292 

matrices 327 

porte polishers 353 

Jagged teeth in tongue diseases. 759 

Jaw, anchylosis of. 182 

fracture of. 623 

Jenner on rickets 224 

Jourdain on aphthae...., 684 

Kane, E. K., Dr., on cold as a 

cause of tetanus 187 

Keloid tumors 949 

Kennicott on pulp capping 392 

Kinds of tongue-tie 801 

Kingsley's obturators 1056 

Kolbe's gag 207, 1029 

Lacerated foramen 50, 51 

Lachrymal bone 54 

canal 31, 35, 46, 54 

tubercle 35 

Lancing the gums 115 

hemorrhage from 115 

treatment of 115 

Langenbeck, osteoplastic resec- 
tion 1065 

Larry, Baron, on tetanus 187 

Leeches in periodontitis 154 

Lenticular ganglion 87 

Lepidoid growths 948 

Lepra '. 138 

Lichen 137 

Lingual nerve 85 

neuralgia 784 

Lipoma, simulating ranula....... 698 

Lips 57, 58 

eversion of 1075 

inversion of 1074 

Lip-stretcher 1066 

Local consideration of dental 

caries 250 

features of dental abscess.... 170 

Localized stomatitis 113 

Lockjaw 182 

Loose fragments in jaw fractures 635 

Lupus......... 139 

Luxation of inferior jaw 637 



Mack's retaining screws 346 

in contour filling 346 

in pivoting 464 

Maculae 139 

Making upper lip , 987 

Malar bone 53 

Malformation of gums 547 

Malgaigne, cheiloplasty 982 

Mallets in filling teeth 343 

Materials used in capping dental 

pulp 393 

in filling teeth 281 

in taking impressions 469 

Matrices, in filling teeth 301 

Jack's 327 

Maxillary bone, inferior, anat- 
omy of. 38 

condyloid process 40 

inferior dental foramen 40 

mental foramen 39 

mental process 39 

mylo-hyoid ridge 40 

ramus 39 

sigmoid notch 39 

bone, superior, anatomy of 33 

alveolar processes 31, 34 

articulations 38 

malar processes 35 

muscles of 38 

nasal processes 35 

palatine process 37 

tuberosity 31, 34 

zygomatic surface 36 

caries 552 

enlargement 142 

fractures 623 

necrosis 566 

Mayo, experiments of, on func- 
tions of fifth nerve 90 

McQuillen on interglobular 

spaces in dentine 99 

on microscopy of morbid 

growths 836 

on orthodontia 484 

McQuillen's extension finger 311 

metal cap in periodontitis... 154 
Means of dryness in dental opera- 
tions 308 

Barnum's rubber dam 313 

Dibble's saliva-pump 310 

Flagg's tongue-holder 308 

Forbes's fork 320 

Hawes's compressor 309 

Hodson's appliances 313 

hot-air syringe 321 

McQuillen's extension finger 311 

• Morrison's compressor 309 

napkin 308 

porcelain tongue-thimble... 310 

Bich's duct compressor 311 



INDEX. 



1085 



Means of dryness in dental opera- 
tions : 

Smith's compressor 810 

Taft's extension finger 311 

Means used in finishing fillings.. 355 

Meatus, inferior 49 

middle 45, 48 

superior 49 

Mechanical pressure in treatment 

of anchylosis 200 

in treatment of ranula 707 

Mechanism of asphyxia 436 

Meckel's ganglion. 52, 82 

Medullary carcinoma 914 

Melanoid naevi 954 

Melanoma 815 

Meliceroma 815 

Menstrual period and anesthe- 
sia 450 

Mental foramen 31, 39 

Mercurial enlargement of tongue 767 

exostosis 836 

impressions 534 

necrosis 568 

ulceration 767 

Mercury in tetanus 191 

Merry's drill 290 

Metal pivots 462 

Metallic ligatures 608 

Metals as a cause of dental ca- 
ries 269 

Metz's nasal speculum 657 

Microscopical analysis of oral 

debris 261 

anatomy of teeth 99 

view of encephaloid section 916 

of epithelial section 920 

Miliaria 139 

Milk teeth 93 

Model of jaws, making.. 473 

Modified hare-lip operation 964 

Moist and hot applications in 

neuralgia 733 

Molar teeth 96 

Moles 946 

Molluscum 139, 948 

Monsel's solutions of iron in epi- 
thelioma 927 

in hemorrhage 116 

in odontalgia 143 

Morphia in cancer 928 

in neuralgia 733 

Morrison's engine 290 

tongue-holder 309 

Mortality of infants Ill 

Morton, Dr. T. G-., operation for 

anchylosis of jaw 210 

Mother-marks 139 

Mott's operation for jaw anchy- 
losis 981 



Mouth, features of 57, 58 

floor of 40 

mirrors 305 

mucous membrane of 72 

offices of 57 

roof of 58, 65 

sectional expression of 65 

washes for 257 

wounds of 598 

Mouth-stretcher used in atresia 

oris 978 

Mucoid sarcoma 879 

Mucous cysts 72 

engorgement of antrum 667 

follicles 72 

membrane of mouth 60 

Multiple cysts of antrum 872 

Muscles, artificial 991 

of expression ,. 59 

Myeloid tumors 879 

Myeloma 815 

Mylo-hyoid ridge of inferior 

maxilla 40 

Myxoma 815 

Njsvi 139, 937 

treatment of 937 

by caustics 941 

by compression 941 

by electrolysis 942 

by excision 939 

by injection 941 

by piecemeal removal.. 944 

by strangulation 940 

Napkins, dental 308 

Narcotics in tetanus 191 

Nasal bone 32, 52 

cavity 44 

groove 43 

nerve 37, 43 

process 43, 113 

speculum 657 

Naso-palatine ganglion 87, 89 

Neck of tooth 27 

Necrosis, alveolar 568 

definition of 566 

dental 568 

exanthematous 565 

mercurial 568 

phosphoric 568 

syphilitic 568 

traumatic 565 

Nelaton's method in reduction of 

jaw luxations 642 

Nerve, anterior dental 88 

a ur iculo-tem poral 85 

buccal 85 

ciliary 81 

deep temporal 85 

facial 62 



1086 



INDEX. 



Nerve, fifth 77 

excitor to portio dura.. 92 
exciter to respiratory- 
nerves 92 

functions of 90 

frontal 80 

ganglionic 81, 82 

inferior dental, section of.... 32 

inferior maxillary 79, 83, 90 

infratrochlear 81 

labial 83 

lachrymal 80 

lingual or gustatory 85 

masseteric 85 

nasal 80,83 

naso-palatine 37, 43, 89 

of the face 62 

tongue 71 

ophthalmic 79, 90 

orbital 82 

palpebral 83 

portio dura 62 

posterior dental 82 

pterygoid 85 

superior maxillary 79, 81, 90 

supraorbital 80 

supratrochlear 80 

trifacial 77 

trigeminus 77 

Nerve, sections of. 1069 

Carnochan's operation. 1072 
Pancoast's operation.... 1072 
sections of inferior maxil- 
lary 1069 

of superior maxillary... 1071 

Neuralgia 709 

causes of. 711 

from depression 714 

from derangements in res- 
piration 713 

from gout 710 

from granules in dental pulp 375 

from miasma 710 

from rheumatism 710 

from syphilis 710 

illustrative cases 717 

nature of. 710 

not a disease 710 

pain of 709 

relations of tobacco with.... 717 

Neuroma 815 

Nitrous oxide gas 454 

liquid 454 

surgeon's case 454 

Nodular dentine 379 

Nodules of enamel 353 

Non-explainable tumors 874 

Non-specific exostosis 834 

Notch, in hare-lip 962 

sigmoid 962 



Obstruction of submaxillary 

duct 705 

Obturators 1030 

dies for making 1034 

fixing in the mouth , 1036 

impressions for 1038 

models for , 1033 

by Buckingham 1040 

by G-arangeot 1055 

by Kingsley 1057 

by McGrath 1038 

by Pare 1054 

by Snell 1055 

bv Stearn 1056 

by Wildman 1048 

Occipitofrontal bandage 633 

Odontalgia from confinement of 
pus and gas in pulp cham- 
ber 372 

from disease of periodon- 

teum 149 

from exposure of dental pulp 

to sources of irritation 365 

from granules in pulp 374 

from recession and absorp- 
tion of gum and alveolus. 380 

from sensitive dentine 361 

from sympathy 380 

Odontocele ". 31, 850 

Odonto-cephalalgia 380 

Odonto-gastralgia 380 

Odonto-otalgia 361 

Odontoma 853 

(Edema of glottis 528 

Offensive odor of saliva 257 

Offices of uvula 529 

Oidium albicans 675 

Oilier, exposure of maxillary 

tumors 1065 

Opacity of the teeth 373 

Operations about the cheeks and 

lips... 952 

for treatment of neuralgia... 737 
for treatment of tongue- 
tie ~ 801 

on oral commissure 987 

Opercula 101, 105 

Ophthalmic nerve 79 

Opisthotonos 187 

Opium and lead in hemorrhage. 115 

Oral fungi 259 

Orbit 31 

Orthodontia 478 

Osseous tumor M 840 

Ossific diathesis 833 

Osteoma 815 

Osteoplasty 283 

Ostitis during dentition 568 

preceding necrosis 566 

Otic ganglion 841 



INDEX. 



1087 



Oxychloride of zinc 283 

" as a capping for exposed 

palps 891 

as a filling for carious teetli 283 

Ozaena, causes of. 644 

from accumulation and de- 
generation of antral 

secretions 644 

caries and necrosis 655 

caries of osseous walls of 

antrum 654 

degenerated pus from 

tooth abscess 645 

deteriorated secretions 

from systemic causes. 652 

lodgment and retention 

of foreign bodies 655 

ulceration of antral lin- 
ing 646 

Paget on healing wounds 961 

Palate bones 41 

Pain tine defects and treatment 

of 1009 

process 37 

Pancoast, operation in cheilo- 

plasty 981 

Papillae of tongue 70 

circum vallate 70 

filiform 71 

fungiform 70 

of teeth 101, 104 

Papulae 137 

lichen 137 

prurigo 137 

strophulus 137 

Paralysis, facial 739 

of cheek 989 

artificial muscle used for 991 
treatment of, by opera- 
tion 990 

Parasites, oral 259 

Parasitic cysts 817 

Parotid gland 72 

Partial dentures 474 

Parulis 170 

Paste fillings for carious teeth... 284 

Pathology of tetanus 187 

Paul, Dr. J., on food 239 

Pearly teeth 279 

Peculiar articulation 476 

calculi 497 

Pemphigus 138 

Period for hare-lip operation .... 952 

Periodonteum 99 

abscess of 170 

affecting antrum 661 

inflammation of 149, 372 

Permanent ranulse 699 

Permanent teeth 93 



Petronius's obturator , 1054 

Pharyngitis leucaemia 549 

Phosphor-necrosis 584 

complexion in 588 

of upper jaw 592 

salivation in 588 

sequestra of 588 

theory of Dr. Letheby 585 

of Lorinser - 585 

of Von Bibra and Geist 585 

Pigment 945 

Pimples 137 

Pins in hare-lip operation 972 

arranging ligatures about... 972 

manner of using 972 

Pityriasis 138 

Pivot teeth 456 

Plaster of Paris as an impression- 
material 471 

Plasters, use of, in dressing 

wounds 608 

Plastic operations in treatment 

of jaw anchylosis 211 

Plate teeth 467 

Pleurosthotonos 187 

Plugging teeth 280 

instruments used for 341 

Abbott's pluggers 341 

Atkinson's pluggers 338 

Butler's pluggers 339 

Redman's pluggers 324 

Varney's pluggers 340 

Poison, typh , 255 

Pompholyx 138 

Porrigo 139 

Porte polishers 353 

Posterior dental canal 36 

dental groove 36 

dental nerve 36 

palatine artery 37 

pillars of fauces 67 

Predisposing causes of tetanus.. 187 

Pregnancy and anaesthesia 450 

Premature dentition 112 

Premolar teeth 96 

Preparation of mouth for arti- 
ficial teeth 467 

Prescriptions for toothache 366 

Pressure in cleft of hard pal- 
ate 1011 

in epithelioma 925 

in hemorrhage 599 

in ranula 707 

in separating teeth 299 

Primary sac of tooth 106 

Primitive dental groove 101, 104 

Processes of condyloid 40 

of Ingrassias 51 

of keloid growths 950 

Prodroma of tetanus 187 



1088 



INDEX. 



Prognosis in synovitis 183 

Progressiveness of caries 556 

Prophylaxis for phosphor-poi- 
soning 585 

Proposition in etiology by Bill- 
roth 913 

Protoxide of nitrogen 454 

Protrusion of lower jaw 489 

use of occipito-mental sling 

in 490 

Proximal cavities 344 

fillings, finishing 354 

Psoriasis of tongue.... 762 

Pulp of tooth 97, 102 

exposure of 365 

fungoid tumors of 820 

Purkinjean corpuscles in cemen- 

tum 99 

Purpura 138 

Purulent discharge from antrum 664 
Pus and gas in dental pulp 

chamber 372 

Pustulas 139 

ecthyma 139 

impetigo 139 

porrigo 139 

scabies 139 

variola 139 

Pyogenic membrane 170 

Banula 695 

diagnosis of 697 

distinguished from carci- 
noma 708 

hvgrometric tumors simu- 

Tating 700 

lipoma simulating 698 

nature of 695 

salivary and lymphatic ade- 
nitis simulating 701 

salivary calculi, causes of.... 706 

treatment of 696 

by mechanical pressure 707 

by operation 703 

Bashes 136 

Becession of the gums 382, 545 

Becipes employed in neuralgia.. 753 

for tooth powders 258 

Bedman's pluggers 324 

Beduction of maxillary luxa- 
tions \ 639 

Beflex pain from dental pulp .... 373 
Beina's operation for jaw anchy- 
losis 213 

Belation of first to second den- 
tures 142 

of medicines with dental ca- 
ries 267 

of phosphorus to jaw-bones. 584 

of tumors 812 



Bemarks on extraction of teeth. 422 
Bequirements in metals for fill- 
ing teeth 281 

Besection of fractured bones 633 

of inferior maxilla 1014 

of superior maxilla 1064 

Betention of antral secretions... 665 

Bheumatism, combination for... 369 

Bheumatoid arthritis 186 

Bhinoscope, uses of, in ozsena ... 657 

Bich's duct compressor 311 

Bichardson's atomizer 429 

Bickets 220 

Bicord on syphilis 764 

Bidge, mylo-hyoid 40 

Biggs ; s operation for absorbing 

alveoli 382 

Bindfieisch on carcinoma 896 

on caries of bone 552 

on histoid mixed tumors.... 904 

on necrosis 568 

on new formations 807 

Bivinian ducts 74 

Bizzoli's operation for jaw an- 
chylosis .." 209 

Boot filling 388 

I Bose drills 289 

| Bound-celled sarcoma 878 

Bubber-dam 312 

Bubeola 138 

Bules for formation of cavities 

in teeth 356 

for treatment of gun-shot 

wounds 634 

Bumbold's treatment of enlarged 

tonsils 522 

Bupia 139 

Buppaner's treatment of enlarged 

tonsils 521 

Saliva, condition of 276 

corpuscles of 276 

microscopy of 276 

Salivary calculi inducts 706 

fistula? 507 

anatomy of. 515 

anomalous cases of 507, 

511, 513 

causes of 507, 560 

common manner of 

treating 508 

Garretson's operation 

for 509 

Horner's operation for. 509 

glands 72 

Salivation in necrosis 579 

Salt sheet baths 118 

Salter on necrosis. 574 

Sarcoma 815 

Sarcomatous carcinoma 911 



INDEX. 



1089 



Scabies 

Scale? 

Scarlatina 

Scars 

Schneiderian membrane. 



... 139 

... 137 

... 138 

... 607 

... 35 

Scirrhoma 815 

Scirrhus.... 905 

microscopy of 910 

of tongue 769 

Scorbutic exostosis 836 

Scorbutus and antral disease 672 

Screw in extracting tooth-roots. 407 

in jaw anchylosis 209 

in plugging teeth 346 

Scrofulosis 217 

ulcers of. 650 

Scrofulous tumors 837 

Scurvy 536 

Sebaceous tumors 932 

treatment of 932 

Secondary dentine 378 

Section of scirrhous carcinoma.. 770 

Sedatives in treatment of ostitis 568 

Self-explaining cystic tumors.... 896 

Sella turcica 49 

Semilunar ganglion 79 

Sensibility of dentine 359, 361 

Separating files 293 

Septum nasi 43 

Sequestrum of necrosis 582 

Setting pivot teeth.... 456 

Sheet-lead in atresia oris 979 

Shock 600 

Sigmoid notch of inferior max- 
illa 30, 41 

Sigmund, Prof., on syphilis 577 

Simple cysts 846 

tumefaction of maxilla 837 

Sims, Dr. Marion, on cause of 

infantile trismus 194 

Skin-diseases 137 

Sloughing of npevi 945 

Smith, Prof. H. H., on epitheli- 
oma 923 

on shock 601 

Smooth-faced pluggers 337 

Sordes 277 

Sore throat 120 

Source of vitality of tooth 570 

Spasm from dental irritation 130 

treatment of 134 

Spasmodic trismus 205 

Spear drills 289 

Speculum of Duplay 657 

of Limrock 657 

of Metz 657 

Spheno-maxillary fissure 51, 81 

foramen 42 

fossa 81, 82 

Spheno-palatine ganglion 85 



Sphenoid bone 48 

Spiritus nitri dulcis 269 

Splints, external, for jaw frac- 
tures 628 

interdental 630 

Bean's 632 

G-unning's 630 

Sponge gold 282 

Spots" 137 

Spurious ranula 706 

Squamaa 138 

ichthvosis 138 

lepra" 138 

pityriasis 138 

psoriasis 138 

Stages of staphyloraphy 1018 

Steam's obturator 1056 

Steatoma 815 

Stellwagen's dental case 341 

Stenonian duct.. 73 

compressor 311 

Stomach teeth 95 

Stomatitis 549 

Strophulus 137 

Structural consolidation of den- 
tine 275 

resisting caries 279 

Strumous abscess of tonsil 524 

Studies in complicated hare-lip.. 967 

in obturators 1037 

in plastic surgery 980 

Styles of excavators 287 

Stylo-mastoid foramen 62 

Subcutaneous epithelioma 925 

Sublingual cysts 697 

gland 40 

ducts of 74 

extirpation of 74 

Submaxillary fossa 40 

gland 40, 73 

triangle 40 

Sulphuric acid in treatment of 

osseous caries 561 

Superficial ranula 699 

Superior dental arch 25 

maxillary bone 33 

fractures of 624 

maxillary nerve 79 

section of. 1072 

Surgeon's nitrous oxide case 455 

Surgical relation of anomalies in 

dentition 141 

Swallowing the tongue 803 

Sycosis 139 

Sympathetic neuralgia 743 

odontalgia 380 

Symptoms of jaw fracture 624 

of tetanus 187 

Synonyms 817 

Synovitis 182 



68 



1090 



INDEX. 



Syphilis 225 

Syphilitic adenitis 937 

affections of tonsils 515 

coryza in infants 656 

disease of tongue 760 

epithelial degeneration 922 

necrosis 568 

ozsena 652 

ulcers 577 

ulitis 568 

Taft on cause of dental caries .. 269 

Taft's extension-finger 311 

separa ting-file 294 

Taking impressions 467, 1U33 

trays required for 468 

Tartar 495 

treatment of 503 

use of acids for removing... 504 
use of instruments for re- 
moving 504 

Teeth, articulation of 109 

. bicuspidati 96 

canine 95 

cementum of 97, 98 

crusta petrosa of 96, 97 

cuspidati 95 

deciduous 93 

dentine of 97, 103, 106 

development of, Garretson's 

views on 104 

opinion of Beale, Hux- 
ley, etc 104 

opinion of Goodsir 101 

opinion of Todd and 

Bowman 101 

enamel of 97, 105, 108 

eruption of 104 

order of 106, 112 

permanent 108, 109 

temporary sets 107 

eye 95 

fang of 96, 103 

formation of 101 

incisor 93, 94 

interglobular spaces 99 

microscopical anatomy of... 99 

milk 93 

molar 96 

neck of. 97 

ossification of 102, 105, 108 

papillae of 101, 104 

periodonteum of 97, 99, 105 

permanent 93 

premolar 96 

pulp of 97, 105 

root of. 96, 106 

stomach 95 

temporary 93 

wisdom 96 



Temper in plugging instru- 
ments 308 

of drills 289 

Temperament and antral disease 664 

Temperature and ether 439 

Temporary ranulse 699 

Temporo-maxillary articulation 74 

Test for purity of chloroform... 441 

Tetanus 387 

treatment of 190 

Thimble, porcelain 310 

Thrush 676 

Tic douloureux 92 

Tin-foil 281 

Tincture of belladonna in con- 
gestion of gums 114 

Tissu inodulaire 961 

Tolerance of dead teeth by jaws. 570 

Tongue and its diseases 756 

abscess of 783 

acute inflammation of 778 

carcinoma of 769 

cystic tumors of 776 

epithelioma of 771 

functional expression 756 

holders 309 

Flagg's 309 

Morrison's 309 

Smith's 310 

neuralgia of 784 

surgical diseases of. 758 

syphilitic condition 761 

tubercle of 775 

Tonsil glands 516 

ablation of 526 

acute inflammation of..... 517, 526 

cysts of. 526 

hypertrophy of. 521 

Tonsillotome 523 

Fahnestock's 523 

Kolbe's 523 

Physick's 523 

Torsion in hemorrhage 599 

Trachea, anatomy of 531 

Tracheotomy 537 

Transplantation of skin 986, 1007 

Traumatic necrosis 568 

Treatment of alveolar abscess ... 176 

of aphthse 690 

of carious bone 557 

of carious teeth 294 

of epulo-fungoid growths ... 822 

of erectile growths 823 

of irregular dentures 479 

of large oral cysts 868 

of nsevi 589 

of non-explaining epulides.. 826 

of periodontitis 153 

of ranulse 696 

of shock 603 



IXDEX. 



1091 



Treatment of synovitis 184 

of ulitis 584 

of umbilical cord 195 

Trismus 182 

dentium 196 

from filling teeth 205 

nascentium ' 193 

tetanoid 207 

traumatic 206 

Tubercles.... 137 

genial 40 

of the tongue 775 

Tubercular 139 

acne 139 

elephantiasis 139 

framboesia 139 

molluscum 139 

lupus 139 

phyrna 139 

sycosis 139 

verruca 139 

vitiligo 139 

Tubular consolidation of dentine 378 

Tumors 804 

Tunica propria of tooth 106 

Typh poison 255 

Typical cancer-cell 811 

Ulcer, aphthous 119 

of dentition 114 

of necrosis 576 

Ulcers 646 

Ulcus rodens 923 

Ulitis 532 

Umbilical cord in infantile tris- 
mus 195 

Unadhesive gold-foil 282 

Upper lip, operation for restoring 987 

Uranoplasty 1028 

operation of Warren 1028 

Urticaria 136, 138 

Utilizing parings in hare-lip.... 963 

Uvula, amputation of. 530 

functions of 58, 528 

Vallet's mass in epithelioma .. 928 

Value of zinc in cancer 928 

Varicella 139 

Variola 139 

Vascular tumors 937 

Veins of face 63 

facial 65 

intermaxillary 65 

temporal 65 

te'mporo-maxillary 65 

Velum palati..., 66 

Venereal exostosis 836 



Venous tumors 939 

Verruca 39 

Verrucous growths 945 

Vesicles 137, 139 

Vesicular 139 

aphtha 139 

eczema 139 

herpes 139 

miliaria 139 

vaccinia 139 

varicella 139 

rupia 139 

Vicarious menstruation 749 

Vidian canal 52, 88 

nerve 52, 88 

Virchow on rickets 225 

on tumors 807 

Virus in wounds 602 

Vitiligo 139 

Vomer, anatomy of 43 

Von Bibra on phosphor-necrosis 565 

Warts on the face 949 

Warty teeth 835 

Waxed threads 359 

Weber's classification of tumors 

of jaw 876 

Wedge plugs 307 

in filling teeth 321 

in orthodontia 491 

Wedl, Prof. Carl, on pulp cavity 377 

Westcott's correcting appliance. 198 

Wharton's duct 74 

White, Dr. J. D., mode of cor- 
recting plate 483 

mode of pivoting 463 

Wildman, nose and obturator.... 1048 

Wire sutures 633 

Wisdom teeth 96 

Wood on aphthse 689 

on functional expressions of 

tongue 756 

Wood pivots 460 

Wood's gag 1029 

Woodward, Dr. J. J., papers on 

histology 917 

on woorara 191 

Woorara in tetanus 191 

Wounds of the mouth 598 

Yellow teeth 276 

Zinc, action of, on teeth 275 

in treatment of cancer 927 

in treatment of caries 364 

used for arrest of hemorrhage 279 

used for purifying amalgam 285 



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